Is Aggressive Therapy the Answer for All Cases of Emphysematous Pyelonephritis: A Report of Three Cases
A 55-year-old gentleman presented to the surgical emergency with complaints of progressively increasing pain and swelling on the left flank, high grade fever and decreased urine output for the last 15 days. He also had a history of extreme weakness and feeling of being unwell for 1 month. He was a known diabetic on oral hypoglycemic agents. On examination the patient was a thin built, sick looking individual, pale, febrile with tachycardia of 110/min. He was not icteric and had no lymphadenopathy. Abdominal examination showed a large area of abscess over the left flank and back covering an area of around 15 × 10 cm, which showed inflammatory changes and evidence of tenderness and crepitus on palpation. The investigations showed a markedly deranged blood urea (150 mg/dl) and serum creatinine (4 mg/dl) levels. The blood sugar was 300 mg/dl but there was no evidence of ketonuria at time of admission. An ultrasound (USG) of the abdomen was performed and the left kidney showed evidence of air in the parenchyma, which was extending up to the parietes, suggestive of emphysematous pyelonephritis. Computer tomography (CT) scan was done which showed the left-sided kidney to be enlarged with multiple air lucencies extending up to the skin and subcutaneous tissue [Figures and ]. Since the inflammatory material had already spread to the parietes, and due to poor general condition of the patient, a decision for incision and drainage was taken under local anesthesia. The wound was left open after draining the gas and the purulent material that were reaching up to the level of the left kidney. The patient was started on broad spectrum antibiotics and the pus sent for both aerobic and anaerobic culture. The anaerobic culture was negative. The gram stain showed gram negative cocci. The pus came out positive for Klebsiella, which was sensitive to the antibiotics already being used. The patient was started on human insulin on sliding scale to control the deranged sugar profile. The patient started responding to this treatment within the next 24 h with fever subsiding and there was improvement in the general well being of the patient. The patient's blood urea and creatinine levels progressively decreased to stabilize at urea (60 mg/dl) and creatinine (2 mg/dl). The patient's urine output was adequate at all. times during the admission period. The patient was subsequently discharged after a period of 3 weeks with minimal discharge from the surgical site and is doing well after 6 months of follow-up.