Images in Clinical Medicine
Emphysematous Pyelonephritis
N Engl J Med 1999; 341:737September 2, 1999
- Article
Figure 1 A 47-year-old woman with obesity and poorly controlled diabetes mellitus presented with a five-day history of fever, dysuria, and left-flank pain refractory to intravenous antibiotics and intravenous fluids. On admission, her blood urea nitrogen concentration was 90 mg per deciliter (32 mmol per liter) and the serum creatinine concentration was 3.7 mg per deciliter (327 μmol per liter). Computed tomography of the abdomen revealed an enlarged left kidney with intraparenchymal and perinephric collection of air (arrow in Panel A). Gerota's fascia was inflamed and thickened (arrowhead in Panel A). Given the high risk of death associated with conservative therapy in this disorder, we immediately performed a radical left nephrectomy. The excised and bisected kidney was hemorrhagic, necrotic, and grossly purulent (Panel B). The collecting system was filled with exudative pus (arrows in Panel B), and the renal capsule was markedly thickened (arrowheads). Staining of the renal tissue with hematoxylin and eosin revealed extensive necrosis, marked polymorphonuclear infiltration, and microabscess formation (Panel C, ×200). Cultures of urine, blood, and renal tissue grew Klebsiella pneumoniae. Postoperatively, the patient required ventilatory and inotropic support for 11 days and was sent home 15 days after admission with a serum creatinine concentration of 1.4 mg per deciliter (124 μmol per liter). Management of her diabetes was optimized by nutritional counseling, weight reduction, treatment with oral hypoglycemic drugs, frequent blood glucose monitoring, and close follow-up with her primary care physician.
Mohamad Ali S. Eloubeidi, M.D., M.H.S.
Vance G. Fowler, Jr., M.D.
Duke University Medical Center, Durham, NC 27710- Citing Articles (2)
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