Is Aggressive Therapy the Answer for All Cases of Emphysematous Pyelonephritis: A Report of Three Cases
A 50-year-old lady presented to the surgical emergency in a condition suggestive of shock. The patient was immediately resuscitated and two large bore cannulas were inserted and ringer lactate solutions were started. Patient was put on oxygen by mask. The pulse at time of admission was 130/min but the blood pressure was un-recordable. After 1 h of resuscitation the systolic blood pressure became 70 mmHg. The patient was then started on ionotropic support. During this period the rest of history and examination was conducted. The patient was a known diabetic on oral hypoglycemic agents. The patient developed high-grade fever, nausea, vomiting and right-sided abdominal pain for the past 1 week. The patient was in anuria for the past 3 days. The patient started developing abdominal distension along with constipation for the past 3 days. Examination revealed all the peripheral signs of hypovolemic shock. The patient was dehydrated with sunken eyeballs and dry tongue. The patient was drowsy and responding only to painful stimuli. The patient's abdomen was distended with board like rigidity and tenderness, along with crepitus palpable on the right lumbar region. A clinical diagnosis of perforation peritonitis, septicemia with shock was made. The patient had already got a CT scan from another hospital before coming to our hospital, which showed gas under right dome of diaphragm. The right kidney was replaced with gas lucencies and was markedly enlarged. The patient was diagnosed as emphysematous pyelonephritis with pneumoperitoneum. The patient was taken for emergency exploration but no visceral perforation was found. The pus sent for culture grew Klebsiella species. The patient had a turbulent postoperative period and did not survive beyond six hours of surgery.