Critical Care

SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV

SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

Source Control in Necrotizing Urinary Tract Infections

Aritra Sen MD* Pratik Doshi MD; and Bela Patel MD UT Health Science Center, Houston, TX

INTRODUCTION: This case discusses management options to reduce high mortality resulting from sepsis and multiorgan
failure from emphysematous pyelonephritis.
CASE PRESENTATION: 50 year old Caucasian male with history of neurogenic bladder and diabetes mellitus type II presented
with increased respiratory distress and confusion. He was intubated and found to be in DKA secondary to pyelonephritis. CT scan
showed right sided emphysematous pyelonephritis with gas in collecting system and ureter along with left sided acute
pyelonephritis. The patient required pressor support and was unable to be weaned from the ventilator. He became oliguric with
subsequent destruction of tissue planes around his kidneys. Percutaneous nephrostomy tubes were placed but were unsuccesful in
draining urine and pus. The patient was deemed not a surgical canddiate due to systemic inflammation and hemodynamic
instability. The patient required CRRT during his hospitalization. He developed ARDS, pleural effusions, atrial fibrillation with
RVR, decubitus ulcers, coagulopathy and ischemic liver during his two weeks in the intensive care unit. After two weeks, he was
succesfully extubated but became dialysis dependant.
DISCUSSION: Hyperglycemia, impaired tissue oxygenated (DM vessel disease) and mixed acid fermentation from
Enterobacteriae family contribute to emphysematous pyelonephritis. Due to its multifactorial component, this necrotizing
infection often does not respond to intravenous antibiotics alone. The Huang Tseng CT Classification system recommends
percutaneous drainage when gas extends into renal parenchyma. If percutaneous drainage is succesful, the patient should respond
to antibiotics and rescucitation within 24 hours. If the patient does not respond, open surgical drainage/nephrectomy are highly
recommended to remove the source of infection. As antibiotics alone may not be able to reach the area of necrosis, removal of the
source is important in preventing multi-organ failure.
CONCLUSIONS: Emphysemetous pyelonephritis is a rare infection seen in diabetics and immunocomprised patients. Although
there are no definiite guidelines, source control becomes the paramount issue in preventing multi-organ damage from sepsis.
Percutaneous nephrostomy tubes can relieve urinary obstruction and pus from infected tissue and is often necessary as antibiotics
CRITICAL CARE

alone are not able to fight the infection. If percutaneous infection does not result in hemodynamic stability, open surgical
drainage/nephrectomy may be indicated. A multimodal team of intensivists, surgeons and interventional radiologists are often
needed to determine which strategy should be utilized to avoid mortality.
Reference #1: Emphysematous Pyelonephritis- a Rare Surgical Emergency Presenting to the Physician: a Case Report and Literature
Review. Saxena et al Indian Journal of Surgery (June 2013)
Reference #2: Emphysematous pyelonephritis: Time for a management plan with an evidence based approach Aboumarzouk et al
Arab Journal of Urology 2014
DISCLOSURE: The following authors have nothing to disclose: Aritra Sen, Pratik Doshi, Bela Patel
No Product/Research Disclosure Information
DOI: http://dx.doi.org/10.1016/j.chest.2016.08.453
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

440A [ 150#4S CHEST OCTOBER 2016 ]