Emphysematous pyelonephritis with IVC thrombus in new onset diabetes mellitus
A 48-year-old, premenopausal lady was admitted with constant and dull aching right sided flank pain of a week's duration. She had a fever for three days and three episodes of gross painless hematuria without clots. She had decreased urine output for 5 days, but no lower urinary tract symptoms. She was recently diagnosed to have diabetes mellitus but was not on any anti-diabetic measures.\nOn examination, she was febrile, with pulse rate of 90/min and blood pressure of 120/80 mmHg. She was not anemic or icteric and was fairly well hydrated. Abdomen was soft with no distension but tenderness was present in the right renal angle without any mass. External genital examination and per vaginal examination were normal.\nHer laboratory results were notable for a raised total leukocyte count with increased polymorphs and the platelet count was 180,000cells/cu.mm. Urine examination revealed deposits showing plenty of WBC and 20-25 RBCs/hpf. Urine culture and sensitivity showed E. coli 103/hpf, sensitive to amikacin, piperacillin-tazobactum, and cefoperazone sulbactum. Blood culture was sterile. Renal functions showed blood urea of 120 mg/dl, serum creatinine of 5.4 mg/dl, serum sodium of 130mEq/dl, serum potassium of 4.2mEq/dl. Serum prothrombin time, activated Partial Thromboplastin Time (APTT), assay of antithrombin III, proteinC, proteinS, and anti-phospholipid antibodies were normal.\nX-ray KUB showed colonic shadows displaced downwards and the right renal area was occupied by gas shadows. Right kidney measured 14 cm × 4.4 cm and hyperechogenic gas shadows were observed on the ultrasonogram (USG). Left kidney measured 10.2 cm × 3.8 cm. Coticomedullary differentiation and pelvicalyceal system were normal [].\nContrast enhanced computed tomographic scan of (CECT) revealed right kidney enlargement with perinephric stranding, air pockets in the pelvicalyceal system, parenchyma, and deep to the Gerota's fascia. A thrombus was seen in the right renal vein, extending into the IVC. Color Doppler confirmed the findings [-]. Diethylene triamine pentaacetic acid (DTPA) isotope study was deferred due to raised renal parameters. The patient was started on injection Piperacillin with tazobactum, 4.5 g IV twice daily for 7 days. Metronidazole 500 mg IV thrice daily was also started empirically to cover anerobic infections. She was also anticoagulated with Heparin 5,000 units IV four times a day. She was hemo-dialysed 4 times and her urine output improved to 1.5-2L/day. Her serum creatinine decreased to 2 mg/dl and blood urea of 62 mg/dl in a week's time.\nThe patient improved symptomatically and repeat USG color Doppler showed complete recanalization of the IVC thrombus and partial recanalization of the right renal vein thrombus. As she was considered high risk for any other surgical procedure, cystoscopy and right sided double J stenting was performed under local anesthesia and her urine output improved to 3L/day. A DTPA scan showed right differential function of 33% and total glomerular filtration rate (GFR) was 59 ml/min [].\nThe patient became symptom free and was discharged. She is on regular follow up now and a repeat CECT and magnetic resonance imaging (MRI) showed the right kidney with improved function even after 3 months [ and ].