Jennifer Hines and Richard Shellenberger
Emphysematous pyelitis is a rare infection of the renal pelvis occurring alone or in association with pyelonephritis. The most common cause is E. coli and diabetes is the strongest risk factor. In a retrospective review including 48 patients who were diagnosed with either emphysematous pyelitis or pyelonephritis, the mean patient age was 60 years old and women outnumbered men 6:12. The most common initial symptoms include fever, dysuria, abdominal pain, and flank pain. The most frequent organ system involvement is hematologic and renal. Our patient, a 76 year old female, with no past medical history, presented with progressive weakness followed by the onset of jaundice. Her exam was notable for hypertension but no fever, jaundice, epigastric/right upper quadrant abdominal tenderness or peritoneal signs. Labs were remarkable for a profound leukocytosis, anemia, cholestasis, and an elevated creatinine. An abdominal ultrasound did not reveal cholecystitis or a common bile duct obstruction. Empiric antibiotics to include Ceftriaxone and Flagyl were started for possible cholangitis. On hospital day two, an abdominal endoscopic ultrasound was performed in lieu of a contrast study as renal function had worsened. This examination was normal. A non-contrasted CT scan of the abdomen and pelvis demonstrated the unusual findings of emphysematous pyelitis with a surrounding fluid collection concerning for a perinephric abscess. Subsequent management included placement of a percutaneous nephrostomy tube and antibiotics. Emphysematous pyelitis presenting as cholestasis is a novel clinical presentation of a rare illness.
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