Emphysematous pyelonephritis E. W. Ramsey, m.b., f.r.c.s. (Edin.), f.r.cs. (Eng.), f.r.cs.[c], S. A. Awad, m.b., f.r.cs.[c] and P. A. F. Morrin, m.b., f.r.c.p.[c], Kingston, Ont.

Summary: A case of emphysematous doit etre suivie d'une intervention was transferred to the Kingston General pyelonephritis with perirenal gas is chirurgicale precoce consistant soit en Hospital on April 10, 1972. presented. This patient underwent un drainage, soit en une nephrectomie, On admission he was drowsy and ap¬ vigorous medical treatment followed selon le degr6 de I'attetnte renale. peared acutely ili. His jugular venous and survived. This pressure was elevated and rales were by nephrectomy at both bases. The liver was a is the present lung condition has high mortality and Emphysematous pyelonephritis 4 cm term to a severe palpable below the right costal should be distinguished from less applied necrotizing margin. Marked tenderness was present in severe infections where gas is confined infection of the kidney in which gas the left costovertebral angle and left to the collecting system. This case is formed in and around the organ. It lower abdominal quadrant. Slight sacral and others previously reported suggest is rarely seen, has a high mortality, edema was noted. His blood pressure was that treatment should initially be and there is difference of opinion as 90/60 and rectal temperature was 38.3 °C. medical, followed by early surgical to the role of surgery in its manage¬ His hemoglobin was 12.6 g/dl, leukocyte intervention of either ment. The case reported here illustrates count 23,400 and erythrocyte sedimenta- consisting tion rate 103 mm in one hour. The results drainage or nephrectomy depending the need for timely surgical interven¬ tion. of blood chemistry studies were as fol¬ upon the degree of renal involvement. lows: sodium 118 mEq, potassium 4.3 Case mEq, chloride 76 mEq, bicarbonate (auto- Resumed Pyelonephrite emphysemateuse report analyzer) 18.5 mEq/1; BUN 111 mg, creatinine 7.9 mg, uric acid 9 mg, blood L'article presente un cas de C.R., a 43-year-old farmer, has been glucose 600 mg/dl. Urinalysis showed a pyelonephrite emphysemateuse a diabetic for 22 years, his diabetes being specific gravity of 1.012, a pH of 5, well controlled with 60 units of neutral 2 + a trace accompagne de gaz protein , of sugar, no acetone, pe>irenal. Apres protein Hagedorn (NPH) insulin and numerous un traitement medical suivi daily. erythrocytes, leukocytes energique Eight years before his present illness he and urate Urine on the d'une ce malade a crystals. output nephrectomie, developed gout which was treated initially day of admission was 600 ml. Urine cul¬ survecu. Cette pathologie, frappee with phenylbutazone and colchicine and ture subsequently proved to be sterile, d'une forte mortalite, doit etre later with allopurinol. Six years later he but both sputum and blood cultures were distinguee d'infections moins severes was found to have a blood urea nitrogen later reported as growing Klebsiella, re¬ ou les gaz sont limites au systeme (BUN) level of 60 mg/dl, and this was sistant to tetracycline, ampicillin, cepha¬ collecteur. de ce cas et attributed to diabetic and possibly gouty loridine and streptomycin. L'analyse His illness d'autres cas similaires de croire nephropathy. present began It was thought that the patient had permet with headache, chills and fever. He was acute renal que la du traitement developed failure superim¬ premiere phase admitted to hospital with a of on a chronic his acute doit etre de nature medicale et diagnosis posed uremia, qu'elle septicemia. He was treated with tetra¬ state having been brought on by septicemia cycline and ampicillin and placed on and obstruction of the left From the Departments of Urology and possibly kidney. Nephrology, Queen's University, Kingston catheter drainage, but his fever persisted A KUB radiograph on admission showed and two weeks later he developed severe mottling over the area of the left kidney, Reprint requests to: Dr. E. W. Ramsey, left flank His treatment was 132 - 404 Graham Ave., Winnipeg, Man. pain. changed but whether this was of significance or R3C 0L6 to gentamicin and cephaloridine and he due to fecal material was not clear (Fig.

FIG. 2A.Definite collection of gas now present in region FIG. 1.KUB radiograph shows mottled gas pattern in region of left kidney, with bubbly appearance characteristic of of left kidney. emphysematous pyelonephritis. 1366 CMA JOURNAL/JUNE 22, 1974/VOL. 110 1). Cystoscopy with left retrograde ure¬ the kidney was found to be completely ter, renal and perirenal gas was present. teral catheterization was carried out. No destroyed by the inflammatory process Turman and Rutherford reviewed the obstruction was encountered, but radio¬ and only occasional areas showed ghost cases of 25 patients reported as having graphs at this stage showed a definite outlines of tubules and rare glomeruli and fibrous stroma His condi¬ emphysematous pyelonephritis pre¬ collection of gas overlying the left kidney, within (Fig. 4). sented two further cases.8 In 20 cases which had a appearance charac¬ tion over the next week, bubbly slowly improved there was and/or teristic of emphysematous pyelonephritis although problems were encountered with radiological surgical (Fig. 2). Gas could also be seen extending mild disseminated intravascular coagula¬ evidence of gas in the renal paren¬ into the tissue planes around the kidney. tion and wound infection. At the time of chyma and the perirenal space and all Vigorous medical treatment was con¬ discharge his BUN was 99 mg/dl and his of these patients were diabetics. Ten tinued, including peritoneal dialysis and serum creatinine 8.8 mg/dl. (50%) of these patients died of their antibiotic therapy with gentamicin and disease. In the other seven patients, cephalothin. The latter was changed to Discussion with one possible exception, the gas chloramphenicol when sensitivities were to be limited to the The diabetes was with appeared collecting reported. managed be: cases were not ex¬ NPH insulin supplemented with intermit¬ Gas in the urinary tract may system, and these tent regular insulin. His condition slowly (1) atmospheric gas introduced by amples of emphysematous pyelone¬ improved and his urine output ranged cystoscopy or trauma, (2) gas from a phritis. Only two of these patients were between Wi and 2 litres per 24 hours. fistula connected with a hollow viscus diabetics and only one patient died. This improvement continued for seven or (3) gas due to infection with gas- It would seem that as the gas-forming days, then a high fever developed and forming bacteria. Gas in the renal area infection spreads from the collecting his condition deteriorated. It was then from infection may occur in the col¬ system to the renal parenchyma and decided to explore the left kidney. On the renal the area, so the and Gerota's fascia a small amount lecting system, parenchyma perirenal morbidity opening or the and there has rise Because of the of No frank was perirenal area, mortality sharply. gas escaped. pus present been confusion with to the confusion in these authors but the perirenal fat was hemorrhagic regard terminology and necrotic. All that remained of the terminology applied to these patho¬ suggested the use of uniform terms to kidney was a stringy necrotic mass and logical entities. As a result recom¬ define the exact pathological process this was removed (Fig. 3). Histologically mendations as to treatment have also (Table I). been confused. In two recent case re¬ Since the above review nine further ports of "renal emphysema" one author cases of emphysematous pyelonephritis recommended vigorous medical therapy have been reported and, along with and avoidance of an operation, while our case, bring the total to 30.2'4"8 All the other suggested that early surgical nine patients were diabetics. Presum¬ intervention (nephrectomy) was in¬ ably the high tissue level of glucose dicated.1'2 Review of these cases shows encourages the production of gas. The that in the former, gas was limited to organism usually involved has been the collecting system, while in the lat¬ E. coli but other organisms including

FIG. 2B.Lateral film shows gas extending in tissue planes around the ?Reprinted with permission of The Williams and Wilkins Company from Turman and Rutherford.5 kidney.

FIG. 3.The gross specimen. On section FIG. 4.Light microscopy shows areas of necrosis with polymorphonuclear no areas of recognizable renal tissue cell infiltration. Most tubules have been destroyed and only a rare glomerulus is were seen. seen. Hematoxylin-eosin xlO. CMA JOURNAL/JUNE 22, 1974/VOL. 110 1367 Ch /Choedyl Expectornt Aerobacter aerogenes, Proteus and Hypertension Klebsiella species have been the cause. Makes breathing more efficient Coliform infections are common in CHOLEDYL diabetics but emphysematous pyelone- DESCRIPTION: Each ivory tablet contains Oxtriphylline a mosaic phritis is rare. In a few cases ureteral (Choline Theophyllinate) 200 mg. Each pink tablet contains obstruction has been present.4"9 Renal Oxtriphylline (Choline Theophyllinate) 100 mg. Each 5 mIs disease of chocolate flavoured syrup contains 50 mg Oxtriphylline ischemia may be a precipitating factor (Choline Theophyllinate). in some cases.2 The distance occurred ACTION: Choledyl (Oxtriphylline) is a theophylline bron- with equal frequency in either kidney chodilator. This choline salt of theophylline is the most and was bilateral in three patients. The solubleof thegroup and when compared to aminophylline, Ser-Ap-Ese high mortality in this condition is shown is less irritating to the gastric mucosa, more readily ab- sorbed from the gastrointestinal tract, more stable and in Table II; 12 (40%) of the patients more soluble. comprehensive died from their disease. All patients Choledyl (Oxtriphylline) is useful for long term therapy received vigorous medical treatment, in Chronic Obstructive Pulmonary Disease (COPD). therapy but whereas 6 (27%) of the 22 patients INDICATIONS: Choledyl (Oxtriphylline) is indicated for undergoing operation died, 6 (75%) of the relief of bronchospasm in obstructive pulmonary dis- * Lowers blood pressure the 8 patients treated only by medical ease. This includes chronic bronchitis, pulmonary emphy- effectively means died. The surgical procedure sema and similar chronic obstructive pulmonary diseases * Increases renal blood flow has usually been incision and drainage (COPD). or nephrectomy. PRECAUTIONS: Concomitant use of other theophylline * Maintains cerebral Initially the contoining preparations may lead to adverse reactions, blood flow treatment of these pa- particularly C.N.S. stimulation in children. tients should be as for any severe pye- ADVERSE REACTIONS: Gastric distress and occasionally * Slows rapid heart rate lonephritis. This review and our present palpitations and C.N.S. stimulation have been reported. * Relieves edema DOSAGE: Adults-initially 200 mg four times daily and * Calms tense patients Table I -Emphysematous pyelonephritis: adjust dosage to individual requirements. Pulmonary em- results of treatment physema 200 to 400 mg four times daily. INDICATIONS Hypertension, especially when complicated by anxiety, Children from 10-14 years-100 mg every 4 hours up to impaired or degenerating renal function or edema. four times daily. From 5-9 years-50 mg (one DOSAGE teaspoonful) One or two tablets, b.i.d., initially, for two weeks; then adjust Treatment No. of patients Mortality every 6 hours up to four times daily. Under 5 years-25 as needed. For maintenance, the lowest effective dosage mg (one-half teaspoonful) of syrup per 15 lbs. body weight, SIDE EFFECTS Surgical 22 6 The side effects are those of the individual component drugs, (27%) every eight hours (tablets not recommended). although with the reduced dosages of each component in the combination the frequency of the side effects is reduced. Medical 8 6 (75%) Serpasil: Lassitude, drowsiness, depression, diarrhea, SUPPLIED: 200 mg tablets in bottles of 100 and 500. increased gastric secretion, or nasal congestion may be 100 mg tablets in bottles of 100. Choledyl Syrup available evident. More rarely anorexia, headache, bizarre dreams, Totals 30 12 (40%) nausea, dizziness. Nasal congestion and increased tracheo- in bottles of 454 ml (16 fl. oz.) and 2272 ml (80 fl. oz.). bronchial secretions sometimes occur in babies of mothers treated with the drug. Symptomatic treatment, such as topical application of nasai vasoconstrictors and/or antihistamines CHOLEDYL EXPECTORANT usually overcomes this problem. Apresoline: Tachycardia, headache, palpitation, dizziness, DESCRIPTION: Each salmon pink tablet contains 200 mg weakness, nausea, vomiting, postural hypotension, numbness case experience would indicate that and tingling of the extremities, flushing, nasal congestion, Oxtriphylline and 100 mg Glyceryl Guaiocolate. Each 5 lachrymation, conjunctival injection, dyspnea, anginal timely surgical intervention will in- mis of cherry flavoured, hydro alcoholic liquid (20% symptoms, rash, drug fever. reduction in hemoglobin and red cell Coint giant urticaria, and a lupus-like syndrome (arthralgia) crease the survival rate in this alcohol) contains 100 mg of Oxtriphylline and 50 mg of in some cases following administration for long periods. fre- Esidrix: Nausea, anorexia. headache, restlessness, nitrogen Glyceryl Guaiacolate. retention, hyperuricemia, hyperglycemia, hypokalemia. Rarely, quently lethal disease. In those with thrombocytopenic purpura, skin rash, photosensitivity, ACTION: Choledyl Expectorant contains the bronchodila- urticaria and agranulocytosis. minimal parenchymal involvement CAUTIONS may but tor Oxtriphylline together with the expectorant Glyceryl Serpasil: Depression may be aggravated or unmasked by drainage suffice, where there Guaiacolate. This combination helps relieve the symptoms reserpine; usually reversible, but sometimes active treatment, including hospitalization for electroshock, may be needed. is extensive destruction of the kidney of bronchosposm as well as obstruction caused by a viscid The drug should be withdrawn two weeks prior to elective surgery; otherwise advise anesthetist. Electroshock therapy nephrectomy will be necessary. As in mucus in the bronchioles. within seven days of withdrawal of the drug is hazardous. Oxtriphylline, the choline salt of theophylline is the most Use cautiously with digitalis, quinidine or guanethidine. the present case the situation may Apresoline: Use cautiously in the presence of advanced renal soluble member of the series. Compared to aminophylline, damage and recent coronary or cerebral ischemia. The drug occasionally be complicated by poor may potentiate the narcotic effects of barbiturates and alcohol. Oxtriphylline is less irritating to the gastric mucosa, better Peripheral neuritis, evidenced by paresthesias, numbness and function of the contralateral kidney, absorbed from the gastrointestinal tract, more stable and tingling has been observed. Published evidence suggests an anti-pyridoxine effect and addition of pyridoxine to the making one hesitate to carry out ne- more soluble. The expectorant component of Choledyl regimen if symptoms develop. is to increase Esidrix: With Esidrix, in prolonged therapy, clinical and/or phrectomy. However, if the emphyse- Expectorant glyceryl guaiocolate which tends laboratory findings for fluid and electrolyte levels should be the secretion and decrease the viscosity of the mucus in the studied regularly, and imbalances corrected. Excessive matous process is widespread through- potassium loss can be prevented by adequate intake of fruit respiratory tract, thus making the cough more productive. juices or potassium supplements. Use cautiously in patients on out the kidney the chance of recovery digitalis, and in the presence of advanced renal failure, INDICATIONS: Choledyl Expectorant is an adjunct in the impending hepatic coma, recent cardiac or cerebral ischemia, of satisfactory function appears to be gout, or diabetes. Hydrochlorothiazide decreases responsive- manogement of obstructive pulmonary disease. It is in- ness to exogenously administered levarterenol (norepinephrine) remote. dicated when both relaxation ex- and increases responsiveness to tubocurarine. Hypotensive of bronchosposm and episodes under anesthesia have been observed in some pectorant actions are required. patients receiving thiazides. Use cautiously in pregnancy. Use Ser-Ap-Es with caution in patients with coronary artery disease, a history of cerebral vascular accidents, peptic ulcer. PRECAUTIONS: The concomitant use of other theophylline CONTRAINDICATIONS References containing preparations may lead to adverse reactions, For Esidrix, persistent oliguria, anuria or complete renal shutdown. For Serpasil, a history of peptic ulcer; or overt particularly C.N.S. stimulation in children. depression. SUPPLIED 1. KANDZARI SJ, MILAM DF: Renal emphysema. ADVERSE REACTIONS: Gastric distress and occasionally Tablets (pink), each containing Serpasil(§ (reserpine) 0.1 mg., J Urol 106: 797, 1971 and C.N.S. stimulation have been Apresoline®) (hydralazine hydrochloride) 25 mg., and EsidrixaS 2. ROSENBERG JW, QUADER A, BRowN JS: Renal palpitations reported. (hydrochlorothiazide) 15 mg.; bottles of 100,500 and 5p00. emphysema. Urology 1: 237, 1973 3. TURMAN EA, RuTHERFoRD C: Emphysematous DOSAGE: Choledyl Expectorant tablets-over 14 years pyelonephritis with perinephric gas. I Urol of age- one tablet four times a day. Tablets are not 105: 165, 1971 recommended under 14 years of age. Choledyl Expectorant 4. BANKS DE JR, PERSKY L, MAHONEY SA: Elixir-children over 14 years-two teospoonsful four times Renal emphysema. J Urol 102: 390, 1969 5. LANGSTON CS, PFISTHR RC: Renal emphy- a day. From 10-14-1 teaspoonful every 4 hours up to sema. A case report and review of the litera- four times daily. From 5-9 years-half a teaspoonful every ture. Am J Roentgenol Radium Ther Nucl 6 hours up to four times daily. Under 5 years-one quarter Med 110: 778, 1970 6. IRELAND GW, JAVADPOUR N, CASS AS: Renal of a teaspoonful per 15 lbs. body weightevery eight hours. emphysema and retention of renal function. SUPPLIED: Choledyl Expectorant tablets in bottles of 100; J Urol 106: 463, 1971 7. CosiTAs S: Renal and perirenal emphysema. Choledyl Expectorant Elixir 227 mIs (8 fl. oz.) Br J Urol 44: 311, 1972 8. BLIZNAK 3, RAMSEYr 3: Emphysematous pyelo- nephritis. Clin Radiol 23: 61, 1972 9. HARROW BR, SLOANE JA: Ureteritis emphy- sematosa: spontaneous ureteral pneumogram; Warner/Chilcott renal and perirenal emphysema. J Urol 89: 0-3062 RDORVAL. QUEBEC 43, 1963 Laboratories Co. Ltmited, Toronto, Canada 1368 CMA JOURNAL/JUNE 22, 1974/VOL. 110