Hyperglycaemic crisis secondary to emphysematous pyelonephritis

A 49-year-old woman presented to the emergency department acutely unwell. Initial investigations revealed hyperglycaemia, ketosis and an acute kidney injury precipitated by urosepsis. She was found to have a new diagnosis of diabetes mellitus (type 2) with a glycated haemoglobin (HbA1c) of 156 mmol/mol. CT imaging of the abdomen and pelvis revealed unilateral emphysematous pyelonephritis (EPN), radiologically classified as stage 3 severity with gas extending beyond the renal collecting system. Escherichia coli was grown on blood and urine cultures. This was sensitive to second-generation cephalosporin cefuroxime. The patient was managed with fluid resuscitation, intravenous antibiotics and renal system decompression with urinary catheter insertion. She was commenced on an intravenous insulin infusion for hyperglycaemic crisis. This case illustrates a rare presentation of hyperglycaemic crisis precipitated by EPN in a patient without a previously known diagnosis of diabetes, successfully treated with medical management alone. Close clinical and radiological follow-up was arranged to monitor the need for future nephrectomy.