Endocrine Abstracts

Introduction: Emphysematous pyelonephritis is associated with high mortality rate. It is seen in patients with a long-standing diabetes. We report a case of a women presenting a septic shock following a severe acute right emphysematous pyelonephritis and requiring salvage nephrectomy.

Case report: A 52-year-old female presented fever with right flank pain. She had a long history of uncontrolled diabetes. Physical examination revealed a with high fever (39°) with tender right loin. Basic investigations reported high blood sugar (33 mmol/l) with HbA1c at 13.2%. Urinary labstix showed negative results for ketones. Biology found renal failure (Creatinine 243 μmol/l) with an hyperleukocytosis (23 × 109/l) and thrombocytopenia (85 × 109/l). kidney, ureter, and bladder (KUB) X-ray revealed no significant abnormality. Ultrasonography showed a right kidney with hydronephrosis upon a 8 mm lumbar ureteral calculus. Left kidney was normal. The diagnosis of acute obstructive right pyelonephritis has been established and antibiotherapy using cefotaxime, amikacin injection and insulin has been immediately started. A double J stent has been also inserted to drain right renal cavities. Despite those measures, our patient continued to be febrile, without improvement of biological parameters. Rapidly, she became sleepy with persistent hypotension, tachycardia and deterioration of renal function. Computed tomography, urgently performed, showed a right emphysematous pyelonephritis (stage III) with gas replacing almost all renal parenchyma and extrarenal extension to pararenal space (Figures 1). Based on the clinical and radiological features, Urologists has performed an urgent right salvage nephrectomy. The removed kidney was gangrenous. She had an uneventful recovery during 5 days in intensive care unit. She received imipenem for 21 days. Renal and tests and CBC normalized. Blood sugar became normal with insulin. Conclusion Emphysematous pyelonephritis occurs mostly in patients with diabetes and a predilection for females. It has a high fatality rate. Therefore, aggressive medical with early surgical intervention is recommended.