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Emphysematous Pyelonephritis Presenting As Pneumaturia and the Use of Point-Of-Care Ultrasound in the Emergency Department

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Emphysematous Pyelonephritis Presenting As Pneumaturia and the Use of Point-Of-Care Ultrasound in the Emergency Department Hindawi Case Reports in Emergency Medicine Volume 2019, Article ID 6903193, 5 pages https://doi.org/10.1155/2019/6903193 Case Report Emphysematous Pyelonephritis Presenting as Pneumaturia and the Use of Point-of-Care Ultrasound in the Emergency Department Natasha Brown,1,2 Paul Petersen ,1,2 David Kinas ,1,2 and Mark Newberry1,2 1Mount Sinai Medical Center, 4300 Alton Rd., Miami Beach, FL 33140, USA 2FIU Herbert Wertheim College of Medicine, 11200 SW 8th St., Miami, FL 33199, USA Correspondence should be addressed to Paul Petersen; [email protected] Received 3 April 2019; Revised 24 June 2019; Accepted 29 July 2019; Published 2 September 2019 Academic Editor: Vasileios Papadopoulos Copyright © 2019 Natasha Brown et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Emphysematous pyelonephritis (EPN) is a rare form of pyelonephritis causing a severe infection of the renal system that includes gas in the renal parenchyma, collecting system and surrounding tissue oen presenting with sepsis. We report the case of a 60-year-old male with poorly controlled insulin dependent diabetes mellitus who presented with abdominal pain, nausea, vomiting, and “peeing air.” CT scan revealed air extending from the le renal parenchyma, perinephric fat and into the bladder, consistent with emphysematous pyelonephritis. Bedside point-of-care ultrasound (POCUS) subsequently revealed dirty shadowing and reverberation artifacts in the le kidney and the bladder consistent with gas in the urinary collecting system. By understanding the identifying artifacts seen with EPN, reective shadow and reverberation artifact, the emergency physician may be alerted to the diagnosis sooner. Oen this illness presents similarly to simple, acute pyelonephritis or undierentiated sepsis. erefore, POCUS allows for real time consideration of this condition while in the emergency department and thus prompter time to treatment. 1. Introduction to our emergency department complaining of generalized abdominal pain, worse in the right upper quadrant (RUQ), Emphysematous pyelonephritis (EPN) is a rare form of nausea, nonbloody, nonbilious vomiting, and fatigue for two pyelonephritis causing a severe infection of the renal system days. e patient’s initial vital signs showed a heart rate of that includes gas in the renal parenchyma, collecting system 103 beats/min, temperature of 36.8°C orally, respiratory rate and surrounding tissue oen presenting with fever, dysuria, of 24 breaths/min, a blood pressure of 145/88 mmHg and an and sepsis of renal origin. e clinical course of EPN is life oxygen saturation of 100% on room air. e patient’s point- threatening if not promptly recognized and treated. We pres- of-care glucose was 514 mg/dl. e patient denied prior med- ent a case of emphysematous pyelonephritis that was diag- ical treatment, however a family member endorsed that he nosed by CT scan but shows specic point-of-care ultrasound had not been taking his insulin injections or sulfonylurea ndings in a 60-year-old diabetic male presenting with vague medications as prescribed. Upon further questioning the complaints of fatigue and vomiting. is case emphasizes how patient admitted to “peeing air”, described as “farting out of point-of-care ultrasound (POCUS) can help in the dierential my penis” for 3 weeks and no urine production for the last day. diagnosis and potentially a more rapid recognition of a serious e physical examination revealed a weak, tachypneic, life-threatening disease. toxic appearing male slow to answer questions who appeared his stated age. He was lethargic, oriented to person, place, and 2. Case Presentation time, with dry oral mucosa, poor skin turgor, fruity smelling breath, and mild tenderness to palpation of bilateral upper A 60-year-old male with poorly controlled insulin dependent abdominal quadrants without costovertebral angle tenderness. diabetes mellitus, noncompliant with his medication presented e rest of the exam was age appropriate and within normal 2 Case Reports in Emergency Medicine Fµ¶·¸¹ 2: Longitudinal ultrasonography of the le kidney showing a- lines (arrows), indicating free air in the renal parenchyma. Fµ¶·¸¹ 1: Axial noncontrast CT scan of the abdomen showing air (arrows) in the le renal parenchyma. limits. Initially, our dierential diagnosis included sepsis, dia- betic ketoacidosis, hyperosmolar hyperglycemic state, and nephrolithiasis/ureterolithiasis. e patient had a prior chol- ecystectomy, making gallbladder pathology less likely. Laboratory results revealed a leukocytosis of 14.44 × 103/µL (4.80 × 103/µL–10.80 × 103/µL) with a signicant le shi, ban- demia of 26% (0%–10%), thrombocytopenia of 38000 × 103/µL (150 × 103/µL–450 × 103/µL), and a lactate of 4.0 mmol/L (0.4– 2.0 mmol/L). e patient was found in new onset renal failure as indicated by a glomerular ltration rate of 14 mL/ Fµ¶·¸¹ 3: Transverse ultrasound of the bladder showing reverberation min/1.73 m2 (>60 mL/min/1.73 m2; GFR = 186 × Serum artifacts (triangles) in the dirty shadow cast by the tissue–gas interface Cr−1.154 × age−0.203 × 1.212 (if patient is black) × 0.742 (if in the urinary bladder. female)) [1] and a creatinine of 4.4 mg/dl (0.70 mg/dl–1.30 mg/dl) which was previously recorded at 0.8 mg/dl. Urinalysis patient to be a high-risk candidate for an emergent operative revealed signicant pyuria with 100 mg/dl proteinuria. e nephrectomy. In consultation with interventional radiology, patient was immediately recognized to be septic and given the patient was managed nonoperatively with a percutaneous broad spectrum antibiotics with aggressive uid resuscitation. nephrostomy tube and le ureteral catheterization performed e patient was given a 30 cc/kg bolus of normal saline and by an interventional radiologist. e urine culture grew intravenous doses of 3.375 g piperacillin-tazobactam and pan-sensitive E. coli and blood cultures returned negative. 600 mg clindamycin pending results of urine and blood cul- Subsequently, the antibiotic regimen was changed to IV ceri- tures. We were concerned that this patient with abdominal axone. He was later discharged on oral ciprooxacin for pain and sepsis in an uncontrolled diabetic had a life-threat- 4 weeks with the nephrostomy tube in place and returned two ening abdominal source of infection. months later for an outpatient le nephrectomy secondary to A 64-slice detector computerized tomography (CT) scan a brotic kidney with multiple adhesions. without intravenous contrast with approximately CTVI 10 mGy dose of radiation was performed which revealed exten- sive le perinephric fat stranding with gas extending from the 3. Discussion le renal parenchyma, perinephric fat, le ureter, and into the bladder (Figure 1) revealing the diagnosis of emphysematous EPN is a rare and complicated bacterial infection of the kidney pyelonephritis. ere was no evidence of obstruction second- that causes severe necrosis in the renal parenchyma, urinary ary to renal calculi, or urinary retention. en, for educational collecting system, and surrounding perinephric tissue. e purposes, a bedside ultrasound of the le kidney and bladder clinical course of EPN is oen critical and has a high mortality was performed using a Sonosite X-porte machine with a cur- if not diagnosed and treated early mainly due to complications vilinear C60x 5-2 MHz probe on the system presetting for from septic shock [2]. Unfortunately, this disease is poorly abdominal imaging. e le kidney showed reverberation reported in the literature as it is usually in the form of case artifacts (white arrows), caused by air in the renal pelvis reports. e most commonly associated factor is diabetes (Figure 2). Subsequent scanning of the urinary bladder showed mellitus; as many as 95% of patients with EPN may have a uid–gas interface in the le upper quadrant of the bladder underlying uncontrolled diabetes [2, 3]. e leading explana- image (Figure 3), also demonstrated reverberation artifact tion for the increased susceptibility to this disease in diabetic (triangular pointers). is is consistent with abnormal gas in patients is that decreased blood ow and high glucose con- the urinary collecting system. Urgent urologic consultation centrations facilitate anaerobic bacterial growth. is disease was obtained, recommending continued conservative man- has also been shown to be associated with drug abuse, alco- agement with uid resuscitation and antibiotics. e patient holism, and neurogenic bladder [3]. According to a review of was admitted to the intensive care unit. Urology assessed the multiple small studies, the female predominance of EPN may Case Reports in Emergency Medicine 3 be as pronounced as 6 : 1, thought to be due to the increased susceptibility to urinary tract infections [2]. e major caus- ative organism for EPN is the same as for urinary tract infec- tion’s in general, which is E. coli [2]. Gas is formed through the fermentation of glucose and lactate which results in the production of high levels of carbon dioxide and hydrogen gasses at the site of the infection [2]. e presentation of EPN can be insidious and similar to noncomplicated pyelonephritis with the most common symp- toms being abdominal pain (94.11%), fever (83.2%) and dysuria (74.5%) [3]. Abdominal pain is generally thought to include ank pain and/or tenderness and its absence should raise a list of alternative diagnoses [3, 4]. Atypical presenta- tions are much more common in uncontrolled diabetics such Fµ¶·¸¹ 4: Longitudinal view of a right kidney showing a calculus was seen in our patient who presented with right upper quad- (white arrow) with posterior clean shadowing (triangles). rant pain. Shock, dened as a systolic blood pressure of less than 90 mmHg, was only present in 16% of patients in one retro- spective study of 74 patients [4]. Positive urinalysis for pyuria was reported to be the most common lab abnormality, which was 79%–100% sensitive [4–7].
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