Is Aggressive Therapy the Answer for All Cases of Emphysematous Pyelonephritis: A Report of Three Cases
A 30-year-old obese lady presented to the surgical emergency with history of pain in the right upper abdomen and back, with a history of on and off fever and generalized ill health for the past 2 weeks. She was a known diabetic but was on irregular treatment and poorly controlled according to the records available. Examination showed the patient to be febrile, along with tachycardia of 110/min. The patient was normotensive at admission. The patient was pale but had no other significant finding on general physical examination. Examination showed an ill-defined tender lump occupying the right lumbar and hypochondrium of approximately 10 × 8 cm size. Because of the tenderness and obesity of the patient the characteristics of the lump could not be elicited fully. Hematological investigations showed a hemoglobin of 5 g/dl and total count of 13,000/mm3. Biochemical investigations showed a blood sugar of 350 mg/dl with ketonuria, deranged blood urea (100 mg/dl) and serum creatinine (3 mg/dl). X-ray of the abdomen revealed air lucencies along the right psoas muscle, but no free air under diaphragm. Because of suspicion of emphysematous pyelonephritis, a CT scan was ordered and this revealed the right kidney enlarged with multiple air lucencies in the parenchyma with non-excretion of contrast, suggestive of emphysematous pyelonephritis [Figures and ]. The patient was explored in the emergency for right nephrectomy. A right nephrectomy with debridement of the surrounding necrotic tissue was done. The pus was sent for culture sensitivity and came out to be positive for Klebsiella species and the patient was then started on appropriate antibiotics. The patient had a turbulent postoperative period with persistent hypotension and oliguria for which she was given ionotropic support, oliguria. She also had a postoperative high-grade continued fever, which continued for 72 h. With the resolution of sepsis, she became afebrile and could be weaned off ionotropic supports. Her recovery was gradual and she was discharged from our care only on the 11th day.