Medical management of emphysematous pyelonephritis: a case report

Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection of the renal parenchyma characterized by gas formation in the renal tissues. It is commonly associated with uncontrolled diabetes mellitus. Although emergency nephrectomy was the standard treatment, recent advances favor conservative management with antibiotics and percutaneous drainage (PCD), reducing mortality and preserving renal function.

A man in his early sixties with poorly controlled diabetes and hypertension presented with a 14-day history of left flank pain, fever, and dysuria. Laboratory findings revealed hyperglycaemia, leucocytosis, elevated serum creatinine levels, pyuria, and glycosuria. Plain radiography and ultrasound revealed gas in the left renal parenchyma. Owing to financial constraints, computed tomography (CT) imaging was not performed. The patient was managed conservatively with subcutaneous insulin and broad-spectrum antibiotics. His condition improved and he was discharged on day 6 with outpatient follow-up, showing renal function recovery.

EPN typically affects patients with diabetes and is often triggered by poor glycemic control, glycosuria, and impaired immunity. Other risk factors included hypertension and obstructive uropathy. Escherichia coli and Klebsiella are common causative organisms. Diagnosis relies on imaging: CT as the gold standard, although ultrasound is useful in low-resource settings. Management has evolved from emergency nephrectomy to medical therapy with or without PCD. Early diagnosis, infection control, glycemic management, and supportive care are essential. Nephrectomy is now reserved for non-responders.

Conservative management of EPN can be effective, even in resource-limited settings, if instituted early, with close monitoring.