Case Report

Culture-Negative Bilateral Emphysematous Pyelonephritis Presented as Acute Renal Failure and Managed Medically Only

Authors: Yalcin Solak, MD, Kultigin Turkmen, MD, Huseyin Atalay, MD, Suleyman, Turk MD


Emphysematous pyelonephritis is a life-threatening infection especially seen in patients with poorly-controlled diabetes mellitus. Imaging modalities (preferably computed tomography) are required to establish the diagnosis. Treatment modalities include volume resuscitation, broad-spectrum antibiotics, percutaneous drainage, and, as a last resort, nephrectomy. We present a case of a 46-year-old female who had hypertension and type-2 diabetes mellitus and presented with complaints of dysuria, back pain, and decreased urine output. Renal ultrasound and abdominal computerized tomography (CT) revealed air-fluid levels at each perirenal region and collecting systems, consistent with emphysematous pyelonephritis. Her clinical situation improved with vigorous fluid resuscitation and broad-spectrum antibiotic treatment.

Key Points

* Emphysematous pyelonephritis is a severe, potentially fatal necrotizing infection of renal parenchyma and perirenal tissues with gas-forming bacteria.

* More than 90% of cases occur in diabetics with poor glycemic control. Other predisposing factors are urinary tract obstruction, polycystic kidneys, end stage renal disease, and immunosuppression.

* Most of the time, imaging modalities, preferentially computed tomography, are needed to ascertain the diagnosis.

* Treatment depends on the severity of the disease. In its mildest forms, broad spectrum antibiotics along with vigorous hydration are appropriate treatment measures. In more severe cases, percutaneous drainage and medical therapy are appropriate. In the most severe cases, bilateral nephrectomy is performed as a last resort.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1.Michaeli J, Mogle P, Perlberg S, et al. Emphysematous pyelonephritis. J Urol 1984;131:203–208.
2.Ouellet LM, Brook MP. Emphysematous pyelonephritis: an emergency indication for the plain abdominal radiograph. Ann Emerg Med 1988;17:722–724.
3.Evanoff GV, Thompson CS, Foley R, et al. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med 1987;83:149–154.
4.Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797–805.
5.Shokeir AA, El-Azab M, Mohsen T, et al. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology 1997;49:343–346.
6.Sujitranooch B. Emphysematous pyelonephritis: a case report and review of literatures. 2008;91:240–243.