Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 47, Num. 1, 2001, pp. 60

Journal of Postgraduate Medicine, Vol. 47, Issue 1, 2001 pp. 60

Letter to the Editor

Percutaneous Conservative Management of Emphysematous Pyelonephritis

Rathod KR, Narlawar RS, Garg A, Lolge S

Department of Radiology, King Edward Memorial Hospital, Parel, Mumbai - 400 012.

Abstract

Sir,

A 75-year-old lady presented with pain in left flank and fever. There was tenderness in left renal angle. On laboratory investigation, patient was found to be a diabetic and in renal failure. A plain film of abdomen showed unusual presence of air in the left renal fossa. Ultrasonography (USG) revealed non-visualisation of left kidney in left renal fossa with strong reflective echoes (‘gassed out kidney’), which was consistent with emphysematous pyelonephritis. Plain computed tomographic (CT) scan revealed the presence of air collections in the left renal and perirenal space with fluid collections. The opposite kidney was unremarkable. Blood culture growed E. coli. Because of high risk for anaesthesia the decision of immediate nephrectomy was deferred. It was decided to manage the patient conservatively with immediate nephrostomy. A percutaneous nephrostomy was performed with Mallecot catheter under ultrasound guidance and the patient was kept on antibiotics and insulin. The patient showed immediate improvement in clinical status within 24 hours. Follow up CT scan demonstrated resolution of perinephric collection.

Traditional therapy for emphysematous pyelonephritis is nephrectomy or open surgical drainage and appropriate systemic antibiotics. (1) However surgical intervention often poses a substantial risk for patients with haemodynamic instability caused by fulminant infection. (2) In addition, lifetime haemodialysis is required for some patients with a solitary kidney or bilateral involvement who have undergone nephrectomy. Therefore, an alternative non operative therapy is desirable.

Hudson et al first described fluoroscopic guided percutaneous drainage for the treatment of emphysematous pyelonephritis in one patient with clinical results. (3) Ming-tan Chen et al described their experience in 25 patients which were treated with percutaneous drainage, in 20 patients antibiotic therapy combined with percutaneous drainage constitutated the only treatment required. (4)

In conclusion, percutaneous drainage with CT or USG guidance is a safe, effective and alternative treatment for emphysematous pyelonephritis that results in cure. This treatment option allows for stabilisation of the patient, treatment of underlying contributory factors and decreased risk associated with nephrectomy if at all required later.

References

1. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology 1997; 49:343-6. MEDLINE
2. Ahlering T, Boyd S, Hamilton C, pagin S, Chandrasoma P, Lieskovsky G, et al. Emphysematous pyelonephritis: a 5-year experience with emphysematous pyelonephritis with 13 patients. J Urol. 1985; 134:1086-8. MEDLINE
3. Hudson M, Weyman P, Van der Vliet A, Catelap W. Emphysematous pyelonephritis: successful management by percutaneous drainage. J. Urol 1986; 136:884-886. MEDLINE
4. Maing-Tan C, Chung-Nung H, Yii-Her C, Chun-Hsiung H, Chin-Pei C, Gin-Chung L Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J. Urol.1997; 157:1569-1573. MEDLINE

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