Images in Clinical Medicine
N Engl J Med 2014; 371:e34November 27, 2014
- A 67-year-old woman with diabetes and poor glycemic control who had recently been treated for pyelonephritis presented to the emergency department in septic shock. She had a 2-day history of fever, flank pain, lethargy, and confusion. Blood tests showed leukocytosis and hyperglycemia. Urinary microscopy revealed pyuria. A scout image was obtained with the use of unenhanced computed tomography. The image revealed extensive gas collection in the parenchyma and perinephric space of the left kidney (arrows) and the left renal vein, with corresponding hydronephrosis and hydroureter. These findings and her symptoms suggested emphysematous pyelonephritis. Immediate radical nephrectomy was performed. Escherichia coli was found on blood cultures, and a course of piperacillin–tazobactam was administered. Despite intraoperative perforation of the bladder, which required surgical repair, the patient had a good postoperative recovery and remained well after the completion of antibiotic treatment, with good glycemic control. Elevated tissue levels of glucose in patients with diabetes may create a more favorable environment for gas-forming bacteria.