Unusual Presentation of Emphysematous Pyelonephritis (EPN): "Double trouble" A Case Report

Introduction: Emphysematous Pyelonephritis (EPN) is a possibly life-threatening condition that is usually present as sepsis. Delay in identifying the disease may lead to detrimental outcomes, even mortality. The present study reports a case of incidental finding of an EPN in a perforated viscus patient. Studies also advocate the minimally invasive approach of percutaneous drainage with antibiotics in asymptomatic EPN patients. Historically, EPN was managed by nephrectomy or open drainage along with antimicrobial therapy but resulted in high mortality of 40-50%. Introduction of percutaneous drainage had shown better outcome compared to nephrectomy.

Case Presentation: A 63-year-old gentleman, with underlying Diabetes Mellitus (DM), initially presented with a sudden onset of severe generalized abdominal pain and distension. Examination revealed peritonitic abdomen. Erect CXR revealed air under the diaphragm suggestive of perforated hollow viscus. Patient underwent exploratory laparotomy with intraoperative findings of perforated prepyloric gastric ulcer that managed with modified Graham patch. Besides, there was also huge retroperitoneal mass. Post operatively, patient subjected for abdominal and pelvic CT that revealed right EPN. It was managed with antibiotic and percutaneous drainage. Patient was responded and recovered.

Conclusion: EPN is a fatal disease that requires early detection with a high index of suspicion particularly in patients with signs of sepsis and pyelonephritis. Although it is rare, in subjects with pneumoperitoneum and the presence of pathology over renal area, EPN should be one of the differential diagnosis. In this case, it is possible that the presence of EPN poses stress to the patient leading to development of perforated viscus.