[Case of emphysematous pyelonephritis with sepsis and disseminated intravascular coagulation]

We present a case of emphysematous pyelonephritis (EPN) with sepsis and disseminated intravascular coagulation (DIC). An 87-year-old man with a history of uncontrolled diabetes mellitus (DM) for more than 25 years was admitted to our hospital for altered mental status and high fever. The initial diagnosis was acute pyelonephritis based on the findings of pyuria and right costovertebral angle knock pain. DIC developed rapidly even though empirical antimicrobial therapy had been started immediately. The abdominal CT revealed the presence of gas in the right renal parenchyma; the definitive diagnosis was EPN. Escherichia coli (E. coli) was identified from both blood and urine cultures. We selected medical conservative therapy with antibiotics because of his advanced age and a history of myocardial infarction three months previously. With only noninvasive therapy and no surgical therapy, his condition improved and he was discharged four months after admission. EPN is a rare, severe gas-forming, necrotizing infection of the renal parenchyma and surrounding areas. Over 90% of the cases occur in DM patients and the most common causative organism is E. coli (60%). The mortality rate with only medical conservative therapy is approximately 20% and transurethral and/or percutaneous drainage or nephrectomy are generally reported to be necessary. To our knowledge, no case with EPN over the age of 84 years has been reported. Although his condition was very severe on admission and long-term antimicrobial therapy was necessary, he was ambulatory at the time of discharge. Herein, we report the pertinent EPN literature and discuss the management of EPN.