A 51-year-old female diagnosed patient with diabetes, hypertension and dyslipidaemia transferred from a local hospital to the emergency department complaining acute abdominal pain and vomiting for four times with reduced urine output for one day duration. On admission she showed positive shock index with a heart rate of 125/min and blood pressure 88/54mmHg. She was afebrile but respiratory rate was around 30/min. The abdomen was soft but tenderness noted in epigastric region. The blood test indicated a leukocyte count 6620 cu/mm with neutrophil predominance of 91%, C- reactive protein (CRP) of 283.6 with platelets of 156x10³ (Graphs 1 & 2). Creatinine level of 252mol/L indicated an acute kidney injury with abnormal coagulation profile PT/INR 1.3, APTT 38.33 suggestive of multiorgan dysfunction (Graph 3). Blood gas analysis showed a compensated metabolic acidosis (pH 7.414, bicarbonate 19, Carbon diaoxide 29.5mmHg) and lactate was 4.9mmol/L.

Initial ultrasound abdomen on admission showed features of right sided pyelonephritis and started on empirically intravenous cefuroxime. Even with IV antibiotic patient didn’t show clinical improvement and urine culture became positive to Klebseilla species and changed to IV meropenem (Figure 1).

And CT showed an image with a right sided swollen kidney with evidence of large air collection around kidney favors emphysematous pyelonephritis with hydroureter and hydronephrosis without a calculus. Urgent urology referral done and emergency right sided JJ stenting done by uro-surgical team. Despite of ten days of IV meropenem and JJ stenting clinical improvement was poor and ultrasound scan repeated which showed in addition to EPN, air containing collection.

The patient underwent retroperitoneal drainage of perinephric abscess and pus send for culture and drain inserted. Pus culture revealed the growth of Klebseilla species sensitive to existing antibiotic therapy and led to a reduction of infectious parameters. The kidney function recovered and coagulation factors stabilized. Initial drain on post-operative day one was 165ml and reduced day by day and it was 18ml on day six.

Reassessment ultrasound scan and X-ray KUB on post-operative day six shows no collection in right sided kidney which was previously noted (Figure 2). Finally, the patient recovered well, mobilized and drain removed. The antibiotic therapy was oralized to co-amoxiclav. Finally, patient has been discharged in freedom of symptoms.

DISCUSSION

Factors associated with pathogenesis of EPN are a high level of tissue glucose, glucose fermenting bacteria, impaired host immunity, decreased tissue perfusion and urinary tract obstruction in nondiabetics [2]. It’s a life-threatening condition and should be promptly treated.

The clinical features of EPN and pyelonephritis are indistinguishable. Most complains fever, chills, flank or abdominal pain. Severe EPN may present with septic shock which is associated with high mortality rate [6]. EPN can be reliably diagnosed by non-contrast CT abdominal imaging. And it remains as a gold standard in diagnosis and Huang and Tseng Classification is the most-commonly used tool [2]. Which classify EPN into Class I, II, IIIa, III b & IV. Patients in class I and class II comprise the majority of patients, and respond well to medical treatment with excellent outcome [7].

CONCLUSION

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  Table 3