Presentation
Fever and right-sided flank pain associated with leukocytosis. Long-standing diabetes mellitus.
Patient Data
Partial staghorn calculus projecting over the right kidney and a stone projecting over the proximal third of the right ureter. A subtle but more important finding are numerous gas bubbles over the right kidney fossa and around kidney in crescentic shape.
Partial staghorn calculi in middle and lower calyces and a stone in the proximal third of the right ureter with gas bubbles in the upper parts of the pelvicalyceal system of the right kidney. Fluid collections with air-fluid levels and a large number of gas bubbles are located around kidney contained within Gerota's fascia. A small amount of gas is reaching medially into the retroperitoneal space.
Irregular shape of the right kidney consistent with parenchymal destruction.
A hypodense oval area in segment 7 of the liver is noted 38 mm in long diameter - could represent an abscess or reactive changes in liver parenchyma due to perirenal inflammation - further investigation needs intravenous contrast administration.
The air is noted in the right ureter and bladder what was not seen on x-ray. Right double J-stent is in the correct position.
Fluid in the right pleural space.
Two drainage catheters were placed correctly within the perirenal space. The majority of collections were successfully drained with some remaining fluid collections with gas bubbles in the anterior part of the perirenal space. No gas is seen in the right excretory system.
Unchanged appearance of liver lesion - the contrast agent was not given due to kidney failure.
Fluid in the pouch of Douglas with free calcification within.
Fluid in both pleural spaces.
Case Discussion
Emphysematous pyelonephritis is a serious condition that warrants urgent treatment so early detection and correct diagnosis are important. One differential diagnosis that must be considered is emphysematous pyelitis - a more benign disease where gas production is limited to the excretory system. In emphysematous pyelonephritis (as in this case) gas is seen within and/or around the kidney.
For the educational purposes, it is worth to compare the x-ray and CT scouts with coronal MPR before treatment to familiarise oneself with the characteristics of the gas pattern.
In addition, gas in the right ureter and bladder detected on CT was not seen on x-ray performed the day before. Probably gas was introduced during instrumentation - the placement of a double J-stent.
Treatment in emphysematous pyelonephritis includes intravenous antibiotics and percutaneous drainage (as in this case).
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