Evolving case of emphysematous pyelonephritis in a second renal allograft

Emphysematous pyelonephritis is an acute necrotizing infection with gas in the kidney that portends a poor prognosis. Patients present with sepsis, requiring fluid resuscitation, glucose control, and broad-spectrum antibiotics. Surgical intervention ranges from relief of urinary obstruction (nephrostomy tube or stent), percutaneous drainage or nephrectomy. We present a 51-year-old second kidney transplant recipient diabetic male, suffering from sepsis of unknown etiology which was subsequently revealed to be due to emphysematous pyelonephritis. Percutaneous drainage was performed initially followed by renal transplant nephrectomy after no improvement of his clinical status. Herein, we describe the clinical course and escalation in management.