Nonsurgical treatment of bilateral emphysematous pyelonephritis in a diabetic patient

Bilateral emphysematous pyelonephritis is a rare life-threatening condition affecting almost exclusively patients with diabetes mellitus. Symptoms, which include fever, chills, abdominal and flank pain, nausea, vomiting, dysuria and pyuria, usually mimic those of classic pyelonephritis, and thus clinical suspicion for this urgent condition should be raised in every diabetic patient with similar presentation. Computed tomography (CT) remains the gold standard for the diagnosis demonstrating gas in the renal parenchyma, collecting system or perinephric tissue. Treatment, which should be aggressive, is classically surgical, and early nephrectomy is recommended. Percutaneous drainage associated with medical treatment might be an alternative. Successful exclusively medical treatment has been described but is infrequent and is reserved as an alternative for patients in whom surgical intervention is contraindicated. We report a case of bilateral emphysematous pyelonephritis in an 82-year-old female diabetic patient who presented with symptoms of typical pyelonephritis. Diagnosis was confirmed by CT, and Escherichia coli was identified as the causative factor. The patient was successfully treated medically with intravenous administration of cefepime and amikacin for 14 days and recovered fully. The therapeutical options for this severe but rare condition are discussed.