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|Year : 1983 | Volume
| Issue : 1 | Page : 39-41
Emphysematous infection of the urinary tract. (Report of 3 cases).
Chary KS, Rao MS, Malik NN, Vaidyanathan SS, Chandrasekar DD, Swamy RP, Dash RJ
|How to cite this article:|
Chary K S, Rao M S, Malik N N, Vaidyanathan S S, Chandrasekar D D, Swamy R P, Dash R J. Emphysematous infection of the urinary tract. (Report of 3 cases). J Postgrad Med 1983;29:39-41
|How to cite this URL:|
Chary K S, Rao M S, Malik N N, Vaidyanathan S S, Chandrasekar D D, Swamy R P, Dash R J. Emphysematous infection of the urinary tract. (Report of 3 cases). J Postgrad Med [serial online] 1983 [cited 2020 May 31];29:39-41. Available from: http://www.jpgmonline.com/text.asp?1983/29/1/39/5557
Gas in the renal substance, perirenal area, bladder wall or the lumen of the collecting system may result from infection, penetrating trauma, fistulous communication with the intestinal tract and various diagnostic and surgical procedures. Pathogenic aerobic organisms such as Escherichia, Klebsiella, and Aerobacter and very rarely anaerobic organisms like Clostridium perfringens are known to cause gas forming infections of the urinary tract.,  Diabetes mellitus and obstructive uropathy are the commonest predisposing factors. Roentgenographic evidence of gas in the renal parenchyma or in the bladder wall, in a patient presenting with severe prostrating illness with or without urinary tract obstruction or diabetes mellitus confirms the diagnosis of this entity. Whereas emphysematous pyelonephritis carries a grave prognosis, emphysematous cystitis has earned a good reputation as a benign disease in the developed countries. Awareness of this disease entity and adequate management of diabetes mellitus and urinary tract infection would help in curtailing the high mortality.
A 60 year old diabetic male was admitted with left flank pain of 15 days' duration. Abdominal distension, vomiting, oliguria, and constitutional symptoms were noted during the previous five days. He had lower urinary obstructive symptoms for the past four years. He was being treated by an indigenous practitioner with analgesics, antibiotics, and insulin without, investigations. He was toxic, dehydrated, febrile, drowsy, and jaundiced. His blood pressure was 80/40 mm Hg., pulse rate, 128/minute and the respiratory rate, 40/minute. Investigations showed haemoglobin of 8.3 g%, total leucocyte count of 30,600/mm3 with differential leucocyte count of P92, L8; the peripheral blood film showed a shift to the left with toxic granulations in the polymorphs. Blood urea was 36.21 mmol/1; serum creatinine was 501.6 mcmol/1; blood sugar: 22.4 mmol/1; total proteins: 46 g/1; total bilirubin: 170 mcmol/1; conjugated bilirubin: 136 mcmol/1; alkaline phosphatase: 16.4 K.A.U.; SCOT: 30 IU; and SGPT: 46 IU. Australia antigen test was negative; Bleeding time was 9 seconds and the clotting time, 12 seconds. Prothrombin index was 64%. Blood culture was sterile; however, urine culture showed Klebsiella and no anaerobic pathogens were grown. A translucent rim of gas shadow taking the shape of the bladder was seen in the plain X-ray of the abdomen [Fig. 1A] . No gas was found in the lumen of the bladder or in the renal collecting system. Cystourethrogram showed gas in the bladder wall and multiple diverticula [Fig, 1B]. Urethrogram demonstrated anterior urethral stricture. Post-evaluation film showed descent of the semicircular gas shadow consequent to emptying of the bladder [Fig. 1C ] Urinary drainage was established by passing a 8 Fr. catheter per urethra. The patient was administered penicillin 1 mega unit 4 hourly, gentamicin 10 mg 8 hourly, and chloramphenicol 500 mg i.v., 6 hourly. Twenty-four hours after admission, he developed hepatic pre-coma and gastro-intestinal bleeding which were managed accordingly. General condition deteriorated and he succumbed to Gram negative septicemia and toxic hepatitis.
A 55 year old female diabetic was admitted with history of vomiting and pain in the left lumbar region of three weeks' duration. She was treated with antibiotics and lente insulin by a practitioner prior to admission here. The blood sugar was still fluctuating between 13.4 and 16.8 mmol/1. Following an oliguric episode lasting seven days, she became anuric. She had undergone right nephrectomy for a staghorn calculus elsewhere three years ago. The left kidney was palpable and tender. Investigations showed haemoglobin of 5.2g%; WBC count of 18000/mm3; with a differential leucocyte count of P89 and L11; blood urea was 30.6 mmol/1; serum creatinine was 792 mmol/1; serum potassium was 4.2 mmol/1; sodium was 120 mmol/l and chloride was 90 mmol/1. Chest X-ray showed bilateral bronchopneumonia. Plain X-ray of abdomen showed large amount of gas in the region of left kidney [Fig. 2A]. After correction of dehydration, infusion pyelogram was performed. The pelvicalyceal system was not visualised upto 40 hours thus suggesting the co-existence of renal parenchymal infection along with obstructive uropathy. Her brittle diabetic status was being managed concomitantly. She was administered metronidazole 500 mg i.v. 12 hourly, gentamicin 10 mg 8 hourly and ampicillin 1 g six hourly to cover both aerobic and anaerobic spectrum. Retrograde ureteric catheterisation was performed under local anesthesia. As the catheter was negotiated into the renal pelvis a fast drip of urine was obtained. It was left in place for continuous drainage. Retrograde pyelography showed clubbing of middle group of calyces consistent with the diagnosis of sloughed papillary necrosis. There was no displacement of the pelvicalyceal system [Fig. 2B]. Although the urinary output remained around 1500 ml/24 hours, she continued to be critically ill. Blood sugar at this time was 22.4 mmol/1. Urine culture showed mixed bacterial growth (predominantly Klebsiella). Blood culture was sterile for aerobic and anaerobic organisms. She was treated with intravenous fluids, sodium bicarbonate, with blood pH and pCO2 monitoring and two hourly plain insulin guided by blood sugar levels and antibiotics. Her condition deteriorated and she succumbed to fulminant bronchopneumonia and septicemia.
A 55 year old male was admitted to the emergency services with uncontrolled diabetes and hematuria of 48 hours' duration. The present illness was punctuated with high grade fever associated with chills, dysuria, and increased urinary frequency, He had repeated episodes of urinary infection in the past. Tenderness was elicited in the suprapubic region. Bladder was not palpable. Investigations showed haemoglobin to be 6.8 g%; total leucocyte count: 11,600/mm3 with differential leucocyte count of P84, L16. Urine culture showed a growth of Klebsiella pneumoniae; blood urea was 27.1 mmol/1 and serum creatinine was 660 mcmol/1. Serum potassium was 2.9 mmol/1; blood sugar was 22.4 mmol/1; coagulogram was normal; blood culture was sterile. X-ray of the abdomen revealed semicircular gas shadow assuming the shape of the urinary bladder. The patient was administered intravenous fluids, four hourly insulin with blood sugar monitoring, ampicillin 1 g four hourly, and gentamicin 10 mg eight hourly. Infusion pyelogram helped to exclude obstructive uropathy. With adequate control of diabetes his condition improved and the gas in the bladder wall was no longer demonstrable in the X-ray taken five days later. Serum creatinine was 572 mcmol/1 at the time of discharge and he was advised conservative treatment for chronic renal failure.
Out of 63,979 patients seen by our urology service of this hospital between 1973 and 1981, one case of emphysematous pyelonephritis and two cases of emphysematous cystitis were encountered. All the three patients had diabetes mellitus. Although Escherichia coli is known to be the commonest pathogen, Klebsiella was isolated in these patients. Bailey encountered no fatality in 19 cases of emphysematous cystitis. But, case No. 1 of this series who had urethral stricture succumbed to Gram negative septicemia and liver failure. Another patient with emphysematous pyelonephritis and ureteral obstruction due to sloughed renal papilla also died. Hence it is important to perform prompt investigations (such as retrograde pyelogram, and/or voiding cystourethrogram) to look for evidence of obstruction and if found, provide prompt relief thereby increasing the chances of survival. Another factor contributing to mortality in developing countries is the delay before seeking specialist care for team management of diabetes, obstructive uropathy, and urinary tract infection. Fatality occurred in two cases who were referred to this hospital 5 and 21 days respectively after the onset of their illness. Timely diagnosis and aggressive therapy are important for salvage of these patients. Otherwise, a vicious circle of obstructive uropathy, urinary tract infection, and uncontrollable diabetes is created which, if not intercepted, leads to systemic sepsis and multiorgan failure ultimately resulting to death.
|1.||Bailey, H.: Cystitis emphysematosa. 19 cases with intraluminal and interstitial collection of gas. Amer. J. Roentgenol., 86: 850-862, 1961. |
|2.||Carris, C. K. and Schmidt, J. I3.: Emphysematous pyelonephritis. J. Urol., 118: 457-459, 1977. |
|3.||Godec, C. J., Cass, A. S. and Berkseth. R.: Emphesematous pyelonephritis in a solitary kidney, J. Urol., 124: 119-121, 1980. |
|4.||Maliwan, N.: Emphysematous cystitis associated with Clostridium perfringes bacteria. J. Urol., 121: 819-820, 1979. |
|5.||Rao, M. S., Bapna, B. C., Sodhi, J. S., Datta, B. N., Reddy, M. J., Rao. K. M. K. and Vaidyanathan, S.: Observations on the value and limitations of infusion pyelography in anuric patients. Urol. Internat., 33: 422-426, 1978. |