Emphysematous Pyelonephritis with Extension of Air in the Inferior Vena Cava

Abstract

A 60-year-old gentleman with uncontrolled diabetes (HbA1C- 10.3%), presented with fever and chills, and right flank pain with dysuria for a week with no respiratory symptoms. On examination, he had tachycardia with a pulse rate of 130/min, blood pressure of 96/60 mm Hg, respiratory rate of 20/min, and saturation of 95% on room air. Per abdominal examination revealed left flank fullness (Fig.-1) and tenderness. On laboratory evaluation, he had a leucocyte count of 36700 cells/mm, a platelet count of 4.1 lakhs, and a blood glucose of 385 mg/dl. On the renal function test- serum creatinine was raised - 2.2 mg/dl. Urine analysis showed 25-30 leukocytes/HPF and the presence of sugar and no ketones. The report of urine culture obtained later was positive for Escherichia coli sensitive to Piperacillin + tazobactam. CXR was normal. Computed Tomography (CT) KUB (Fig.-2) revealed thinning of the right renal parenchyma along with large air pockets of perinephric emphysematous changes with the extension of the gas into IVC and left renal vein (Huang and Tseng classification 3b). Considering the above history, examination, and relevant investigation, a diagnosis of emphysematous pyelonephritis with a further extension of air in the inferior vena cava was made. The patient was treated with intravenous fluids, Piperacillin + tazobactam, metronidazole, and insulin. After stabilization, under general anaesthesia, the patient underwent open nephrectomy (Fig. 3) instead of PCN or DJ as the patient was hemodynamically stable, and bedside 2 D Echo did not reveal the extension of the gas into the atrium or ventricles, it was thought that removing the kidney as the source of gas production would curtail the process of intravasation of gas in the IVC. The patient underwent postoperative CT KUB after 72 hours which revealed complete spontaneous resolution of air in IVC (Fig.-4). The patient improved clinically with intensive post-operative care and was discharged after 14 days.