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제목	"Double Jeopardy" an 81-Year-Old Diabetic Woman With Emphysematous Pyelonephritis: A Case Report
저자	Diana Mae Naldoza
출판정보	2025; 2025(1):
키워드	Emphysematous Pyelonephritis , Necrotizing renal infection, Diabetes mellitus
초록	Emphysematous Pyelonephritis (EPN) is a rare, severe necrotizing infection of the kidneys commonly affecting elderly female with diabetes mellitus. Associated with high mortality, early recognition is pivotal to the management. We present an eighty-one year old diabetic woman, admitted due to three-day history of vague abdominal discomfort, vomiting, and fever. Upon examination, she had tenderness on the right loin area. Her medical history included hypertension and chronic renal failure. Her complete blood count showed leucocytosis of 14 x109/L (neutrophils of 89%) , creatinine of 2.1 mg/dL (eGFR of 23 mL/min,) and HbA1c of 9.8%. CT scan revealed a right Emphysematous Pyelonephritis, hydronephroureter, right nephrolithiasis and left kidney perinephric fat stranding. She was started on Piperacillin- Tazobactam, insulin for glucose control, and was referred to Urology service, and underwent emergency Nephrectomy with Ureterolithotomy. On third hospital day, urine culture showed Acinetobacter lwoffi/haemolyticus, sensitive to current antibiotic. She was discharged after two weeks. EPN has an overall mortality rate as high as 42%. Common pathogens includes E. coli, K. pneumoniae, and P. mirabilis, and Enterobacteriaceae. Diagnostic criteria includes symptoms of urinary tract infection, positive urine culture, pyuria, positive CT scan, and absent fistula. Imaging of choice is CT scan, will show gas patterns in the perinephric area, renal veins, psoas muscle, and perinephric abscess. Urine culture is 90% sensitive. Initial management includes fluid resuscitation, empiric antibiotics targeting gram-negative pathogens, and strict sugar control. Although limited, data shows antibiotics along with nephrectomy provide best outcomes. Poor outcomes were related to thrombocytopenia, acute renal failure, altered mental status, and shock. The case demonstrated multiple risk factors, hence uredo-penicillin, aggressive sugar control, hydration, and nephrectomy were done. EPN is a rare, fatal acute infection with heterogenous clinical presentation, hence early recognition and initiation of management in patients with uncontrolled diabetes mellitus improves mortality outcomes.
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