Document Type : Case Report
Authors
1 Department of Medicine, Aja University of Tehran Medical Sciences, Tehran, Iran
2 Department of Medicine, Islamic Azad University of Tehran Medical Sciences, Tehran, Iran
3 Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran
Abstract
Highlights
Keywords
Introduction
The co-occurrence of diabetes with various infections can cause severe infections in the vital organs like respiratory and urinary tracts and appears as pyelonephritis and empyema, causing sepsis with pre-renal abscess and adjacent lung abscess (1). Urinary tract infections are more common, more severe, and carry worse outcomes in patients with type 2 diabetes mellitus (2).
The most common reason for such infection is E. coli infection which can lead to causing rare complications of emphysematous pyelonephritis (3).
Emphysematous pyelitis is the presence of gas localized to the renal collecting system. Emphysematous cystitis is defined as air in the urinary tract. More than half of these patients have diabetes (3). Emphysematous urinary tract infections are upper and lower urinary tract infections followed by gas formation followed by cystitis, pyelitis, or asymptomatic and symptomatic urinary tract infections (UTIs) such as renal and perinephric abscesses and candidiasis. This study presents a strange case of the emphysematous chest wall with progressive loculated empyema and abscess formation post-emphysematous pyelonephritis.
Case presentation
A case of a diabetic single woman weighing 86 kg, 165 cm tall, with poor glycemic control was referred to our department at Sina hospital. The informed consent was completed by the patient to report the case, and the case was reported based on CARE guidelines.
She was under extracorporeal shock wave lithotripsy (ESWL) treatment with renal stones. Still, due to fever, abdominal pain, nausea, vomiting symptoms of lethargy, and general malaise, one week later, on 2017.06.09 was referred again to the emergency department of Sina hospital with an initial diagnosis of sepsis. On kidney, ureter, and bladder (KUB) X-ray imaging, the air was evident in the chest wall and the left kidney, based on the diagnosis of emphysematous infection. After an emergency computerized tomography (CT) scan, abdominal left retroperitoneal abscess, localized empyema, closed left periphery, and fluid-air surface at the base of the left lung (abscess) was identified the patient was diagnosed with pleuritis and pyelonephritis. The result of the laboratory test of the patient is presented in Table 1. After cardiac, pulmonary, internal medicine, and forensic consultation, the patient underwent surgery on 21st June 2018, using a double-lumen right. The patient was placed in an artery line and then underwent a thoracoabdominal incision, first a left lower thoracotomy followed by left lung decortication and abscess drainage. After cleft development to the left paramedical of the abdomen without entering the abdominal cavity in the left retroperitoneum, she underwent a left abscess and nephrectomy, which was performed in the left umbilical artery with both clots and nonfunctional auto-nephrectomy. The chest wall was closed by inserting the renal log drainage, chest tube, and catheter into the pleural effusion. The patient was discharged on 25th June 2018 with oral ciprofloxacin treatment.
Table 1. The result of the laboratory test of the patient over six months
2017.09.08 |
2017.06.17 |
2017.06.12 |
2017.06.11 |
2017.06.10 |
2017.06.09 |
Laboratory test |
102 |
100 |
146 |
|
385 |
|
FBS (mg/dl) |
7 |
8 |
|
|
37 |
66 |
BUN (meq/L) |
0.8 |
0.6 |
|
|
1 |
1.3 |
Creatinine (meq/L) |
125 |
139 |
|
|
131 |
125 |
Sodium (meq/L) |
3.9 |
3.5 |
|
|
3.8 |
4 |
Pottassium (meq/L) |
10.04 |
6.87 |
6.85 |
12.2 |
|
15.41 |
WBC (10ˆ3/mmˆ3) |
4.58 |
|
|
|
|
2.9 |
RBC |
11.5 |
11.1 |
10.8* |
6.9 |
|
8.1 |
Hemoglobin (gr/dl) |
356 |
332 |
349 |
375 |
|
407 |
Platelet (10ˆ3/mmˆ3) |
|
199 |
141 |
|
|
398 |
BS (mg/dl) |
|
|
|
|
|
14.9 |
Hb A1C |
|
|
|
|
|
3.66 |
TSH |
|
|
|
|
|
4.01 |
T4 |
76.5 |
|
|
83 |
|
88 |
Neut % |
14.0 |
|
|
|
|
4.6 |
Lymp % |
|
|
|
E-Coli |
|
Neg |
Blood Culture |
FBS: Fasting Blood Sugar; BUN: Blood Urine Nitrogen; WBC: White Blood Cell; RBC: Red Blood Cell; BS: Blood Sugar; TSH: thyrotropin
Discussion
Abdominal emphysematous pyelonephritis and its association with lung involvement in diabetic patients are very dangerous. They require concurrent treatment in both organs after ICU hospital admission. Emergency blood and urine culture tests, abdominal ultrasound, CT scan with and without injecting, performing a kidney scan with T99, and monitoring blood sugar levels are essential. The occurrence of pyelonephritis associated with diabetes requires urgent hospitalization and prompt treatment. Emergency cystoscopy and necessary measures to remove the obstruction may be needed if there are obstructive symptoms due to stenosis or urinary stricture. Symptoms of sepsis in pyelonephritis patients with concomitant sickness and fever require particular hospitalization and diagnostic and therapeutic measures. The onset of respiratory symptoms following clinical signs indicates the spread of infection from the sub-diaphragmatic to the supra-diaphragmatic. A CT scan of the abdomen, pelvis, and chest with an injection is necessary to examine the retroperitoneal and thoracic space. Although auto-nephrectomy has been reported in chronic kidney disease, especially tuberculosis or trauma, it has been observed in diabetes mellitus and E-coli infection.
Patients with chronic renal tuberculosis develop necrosis and progressive cavitation (4). European physicians have gradually forgotten the diagnosis of auto-nephrectomy over time, with a sharp decline in tuberculosis cases, but it should always be taken into account (5). Some cases of auto-nephrectomy due to trauma have also been reported that have been chronic for many years (6-8).
Conclusions
In our case, auto-nephrectomy caused by pyelonephritis occurred in the context of diabetes and with a history of renal stone, so it seems that diabetic patients should also consider auto-nephrectomy in severe chronic and acute pyelonephritis infection.
Authors’ contribution
All authors contributed equally.
Acknowledgments
Special thanks to the Urology Research Center (URC), Tehran University of Medical Sciences (TUMS).
Conflict of interest
All authors claim that there is not any conflict of interest.
Funding
There is no funding.
Ethical statement
All authors ensured our manuscript reporting adheres to CARE guidelines for reporting case reports.
Data availability
Data will be provided by the corresponding author upon request.
Abbreviation
CT Computerized tomography
EPN Emphysematous pyelonephritis
ESWL Extracorporeal shock wave lithotripsy
KUB Kidney, ureter, and bladder x-ray
PELE Progressive emphysematous
UTI Urinary tract infections