Emphysematous osteomyelitis of the spine with emphysematous pyelonephritis: A rare coexistenceA Singh1, N Kaur2, M Gupta1, S D'cruz1
1 Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
2 Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India
We report a case of a 60-year-old man, who presented to the emergency with complaints of vomiting and burning micturition for 4 days, decreased urine output, shortness of breath, and low back pain for 2 days. There was no history of fever. He did not complain of any weight loss, night sweats, or loss of appetite. He had not been diagnosed with diabetes in the past and was not suffering from any other chronic medical conditions. He was not taking any medications, and his family history was non-contributory. On arrival, the patient was in moderate distress but was alert and oriented to time, place, and person. He was tachycardic (pulse rate: 118/min), but all other vitals were stable. His O2 saturation via pulse oximetry was 94%. Mild tenderness could be elicited at the left costovertebral angle. The rest of the examination seemed grossly normal.
The patient was subsequently hospitalized, with the initial laboratory studies showing neutrophilic leukocytosis (total leukocyte count = 15.5 × 109/L, neutrophils = 90%), elevated urea (289 mg/dl) and creatinine (3.7 mg/dl) levels, random blood sugar of 402 mg/dl, pH of 7.429, bicarbonate (HCO3−) level of 11.4 mEq/L, and blood lactate level of 1.8 mmol/L. Initial impressions indicated an infectious etiology in an undiagnosed diabetic. A urinalysis revealed pyuria, and a urine culture was also sent. An ultrasound of the abdomen revealed normal-sized kidneys, bilateral increased renal parenchymal echogenicity, moderate left hydronephrosis, and evidence of air within the left kidney.
A non-contrast computed tomography (CT) scan was subsequently obtained to further delineate the pathology, which showed a bulky left kidney, few air specks within the renal parenchyma, pelvicalyceal system, and perirenal soft tissue stranding, indicating emphysematous pyelonephritis [Figure 1].
Air was also seen within the lumbar and sacral vertebral bodies, suggestive of emphysematous osteomyelitis, and within pre- and paravertebral soft tissues, retroperitoneum, epidural, and intrathecal space [Figure 2].
A diagnosis of emphysematous osteomyelitis of the spine with coexisting emphysematous pyelonephritis in a previously undiagnosed diabetic patient was made. The patient was started on insulin 50 IU, IV fluids, and ceftriaxone 1 g twice daily. On the second day of admission, medications were adjusted and the patient received 6 units of subcutaneous insulin R three times a day, 6 units of subcutaneous insulin N two times a day, metronidazole 500 mg three times a day alongside piperacillin-tazobactam 4.5 g eight-hourly, and amikacin 500 mg IV twice a day. A percutaneous nephrostomy was considered but was delayed on account of, and thereby to manage, a deranged coagulation profile.
On the third day following admission, urine culture showed the growth of Escherichia coli. The urea and creatinine levels had increased to 311 mg/dl and 3.9 mg/dl, respectively. Unfortunately, despite optimal antibiotic and supportive therapy, the patient's condition deteriorated and progressed to septic shock. In spite of maximal resuscitative efforts, the patient expired 72 hours after admission due to the devastating nature of his condition.
Emphysematous osteomyelitis is a potentially fatal, albeit rare condition caused by gas-forming organisms. The presence of intraosseous air in the right clinical context strongly points toward the diagnosis; nonetheless, common and benign causes such as trauma, degenerative changes, osteonecrosis, and certain neoplasms should also be ruled out., Abscess formation, fluid collection in adjacent tissues, and an extensive and mottled appearance of intraosseous air hint toward emphysematous osteomyelitis. Emphysematous pyelonephritis is seen mostly in diabetic individuals and is characterized by the presence of gas in the renal parenchyma, collecting system, or perinephric tissue., The latter is a relatively more frequently reported condition, but only 46 cases of the former have been reported in the literature as of July 2020. As per our knowledge, the simultaneous presence of emphysematous pyelonephritis and emphysematous osteomyelitis in a patient has only been reported five times in the past, and here, we presented a similar case of this exceedingly rare coexistence.
These both are radiological diagnoses. Although rare, emphysematous infections might be the initial presentation in undiagnosed diabetic individuals. We here illustrated the importance of keeping a high index of clinical suspicion regarding sinister infections and the role of obtaining timely imaging such as CT scans in accurately diagnosing these conditions in patients who present non-specifically. The death of this patient also emphasized the fact that, if widespread, aggressive treatment might not be sufficient in such lethal conditions, and therefore, risk factor management and earliest detection via imaging remain the cardinal pillars of improved patient outcomes.
Declaration of patient consent
Informed consent was obtained from the next of kin of the subject described in this report.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]