Emphysematous pyelonephritis

Last revised by Mostafa Elfeky on 10 Jul 2023

Emphysematous pyelonephritis (plural: emphysematous pyelonephritides) refers to a morbid infection with particular gas formation within or around the kidneys. If not treated early, it may lead to fulminant sepsis and, therefore, carries a high mortality.

The patient usually presents with fevers and flank pain. In diabetics, who are the ones at risk for this condition, leucocytosis and hyperglycaemia are prominent laboratory findings. 

The presence of thrombocytopenia is particularly associated with poor prognosis 3.

It tends to be more common in females, and approximately 90% of patients have uncontrolled diabetes mellitus 1. It may however also be seen in immunocompromised individuals or associated with urolithiasis, neoplasms, or sloughing of papilla.

Causative organisms include:

  • Escherichia coli: usually considered the commonest causative organism 3
  • Klebsiella pneumonia
  • Proteus mirabilis

May show mottled gas within the renal fossa or crescentic gas collection within Gerota's fascia. Linear gas shadows along paraspinal region may also be seen, representing retroperitoneal gas.

  • may show an enlarged kidney with coarse echoes within renal parenchyma or collecting system
  • dirty echogenic foci with reverberation/ring-down artifacts representing gas ('dirty shadowing') may also be seen

CT is the best diagnostic modality for emphysematous pyelonephritis, and it may show the following diagnostic features:

  • enlarged, destroyed renal parenchyma
  • small bubbly or linear streaks of gas 1
  • fluid collections, with gas-fluid levels
  • focal necrotic areas +/- abscess

Gas may also be seen extending beyond the renal parenchyma into the perinephric space. Extension of gas into the retroperitoneum implies breach of Gerota's fascia. 

CT features of emphysematous pyelonephritis can be differentiated into two types 5:

  • type 1
    • greater than one-third renal parenchymal destruction
    • streaky or mottled appearance of gas
    • intra- or extrarenal fluid collections are characteristically absent
    • it is usually more aggressive and lead to death shortly, if not intervened early
    • mortality 70%
  • type 2
    • destruction of less than one-third of the parenchyma
    • renal or extrarenal collections associated with bubbly or loculated gas, or gas within pelvicalyceal system or ureter
    • mortality 20%

In addition to this, the Huang-Tseng CT classification system 4 is also described:

  • class 1: gas in the collecting system only
  • class 2: gas in renal parenchyma only (without extrarenal extension)
  • class 3: gas in renal parenchyma with extrarenal extension
    • class 3a: extension of gas or abscess to perinephric space
    • class 3b: extension of gas or abscess to pararenal space
  • class 4: bilateral emphysematous pyelonephritis or solitary kidney with emphysematous pyelonephritis

In mild cases, treatment is with intravenous antibiotics. Percutaneous catheter drainage of perirenal or retroperitoneal collections can be performed. Severe cases may warrant nephrectomy.

General imaging differential considerations include:

  • emphysematous pyelitis
  • iatrogenic (instrumentation, or intervention of urinary tract)
  • fistulous communication with bowel

ADVERTISEMENT: Supporters see fewer/no ads

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.