Renal emphysema

Share Embed


Descrição do Produto

RENAL EMPHYSEMA JOEL

W. ROSENBERG,

AZHER JORDAN

QUADER,

M.D.

M.D.

S. BROWN,

From the Department

M.D. of Urology,

New York University Medical Center, and The Manhattan Veterans Administration Hospital, New York, New York

ABSTRACT-A case of renal emphysema associated with recent renal infarction and acute pyelonephritis is presented. The clinical and pathologic features are gizjen and the literature reviewed as to prognosis and survival rate with conservative and surgical modes of therapy. It is concluded that aggressive surgical therapy, in the form of nephrectomy, is indicated and often is life-saving therapy.

Renal emphysema is a pathologic condition characterized by spontaneous appearance of gas within or around the kidney. It is most frequently seen in patients who have diabetes mellitus. A review of the literature reveals that 33 cases have been reported since Kelly and MacCallum in 1898’ first described this clinical entity. This report is of an additional case of renal emphysema which demonstrates many classical features as well as some unusual characteristics.

film of the abdomen revealed a collection of gas around the area of the right kidney. Intravenous urogram disclosed nonvisualization of the right kidney and a normal-appearing left kidney (Fig. 1). Cystoscopy revealed hemorrhagic cystitis; a

Case Report A seventy-four-year-old white diabetic man with fever and progressive lethargy was admitted to the medical service. Past history, in addition to diabetes, included arteriosclerotic heart disease, chronic pancreatitis, and parathyroid adenoma treated successfully with adenectomy one year prior to admission. Incidentally, intravenous urography at that time had revealed normal upper urinary tracts. The patient denied he had dysuria, hematuria, and pneumaturia. On admission his temperature was 102” F., but there were no localizing signs on physical examination, including absence of costovertebralangle tenderness. Urinalysis revealed 4 plus sugar and acetone, pyuria, and bacteriuria. Urine cultures grew Escherichia coli. Four consecutive blood cultures also were positive for the same organism. Blood urea nitrogen was 66 mg. per 100 ml., and white blood cells 17,000 per cubic millimeter with a shift to the left. An x-ray

FIGURE 1. alization kidney.

Intravenous

of right

kidney

urogram showing

nonvisuand normal-appearing left

237

right retrograde ureterogram showed no ureteral obstruction. The right kidney was explored through an incision in the subcostal flank. Gerota’s fascia was found to be tense, containing foul-smelling gas. No frank pus was evident. The kidney substance was soft and beefy red with areas of gross infarction and necrosis. A nephrectomy was performed. Postoperatively the patient did well, his diabetes was easily controlled and blood urea nitrogen level returned to normal. Comment Most patients with renal emphysema are critically ill. They usually have diabetes and the causative organism is generally E. coli. This case displayed all of these features. Frequently some degree of obstructive uropathy from either congenital, inflammatory, neoplastic, or calculus disease is the precipitating factor. This, however, did not appear to be a feature in this case. A severe and necrotizing renal infection in the form of acute pyelonephritis is also often present. The spontaneous appearance of gas is due to infection by anaerobic gas-producing bacteria. Most coliform organisms and proteus species can ferment glucose with subsequent production of acid and gas. The most commonly reported organisms with renal emphysema include E. coli, Aerobacter aerogenes and Pseudomonas aeruginosa. In this case pathologic examination revealed acute arterial and venous thrombi with recent massive infarction. There was acute pyelonephritis, papillary necrosis, and cortical abscesses. In addition there was evidence of chronic consistent with diabetic glomerular disease, nephropathy (Fig. 2). We postulate that ischemia, secondary to infarction, predisposed this diabetic

patient to acute pyelonephritis which progressed to abscess formation and renal emphysema. Review of the literature reveals that this condition has been reported in 25 diabetic patients and eight nondiabetic patients.lmzY Only 48 percent (12 of 25) of the diabetic patients survived, while 7 of eight nondiabetic patients made a satisfactory recovery. This obviously would indicate a better prognosis in the latter group. Seven of the eight nondiabetic patients had some form of distal obstruction, including ureteral strictures, obstruction by aberrant renal vessels, and renal stones. In the diabetic group, 17 of 25 patients had surgical procedures, either nephrectomy or incision and drainage. There were six deaths or a mortality rate of 35 per cent in this group, three postnephrectomy and three after incision and drainage. Of the I1 surgical survivors, seven had nephrectomy. The remaining eight diabetic patients were treated conservatively; six from this group died, giving a mortality rate of 75 per cent. It appears that renal emphysema is an infrequent but serious problem with a high mortality rate, especially in patients with diabetes. The patient is usually critically ill. Our experience and review of the literature seem to indicate that early surgical intervention (nephrectomy) is indicated. 560 First Avenue New

1. KELLY, H. A., and MACCALLUM, W. G.: J.A.M.A. 31: 375 (1898). ALEXANDER, J. C.: Pneumopyonephrosis mellitus, J. Urol. 45: 570 (1941).

8.

9.

specimen showing infarction and necrosis and evidence of chronic glomerular disease consistent with diabetic nephropathy.

238

Gross

New

York

10016

References

7.

FIGURE 2.

York,

10. 11.

Pneumaturia. in diabetes

BANKS, D. E., JR., PERSKY, L., and MAHONEY, S. A.: Renal emphysema, ibid. 102: 390 (1969). BRAMAN, R., and CROSS, R. R., JR.: Perinephric abscess producing a pneumonephrogram, ibid. 75: 194 (1956). COSTAS, S.: Renal and perirenal emphysema, Brit. J, Urol. 44: 311 (1972). CLIFFORD, N. J., and KATZ, I.: Subcutaneous emphysema complicating renal infection by gas-forming coliform bacteria, New England J. Med. 266: 437 (1962). GILLIES, C. L. K., and FLOCKS, R.: Spontaneous renal and perirenal emphysema, Am. J. Roentgen. 46: 173 (1941). HARRISON, J. H., and BAILEY, 0. T.: Significance of necrotizing pyelonephritis in diabetes mellitus, J.A.M.A. 118: 15 (1942). HARROW, B. R., and SLOANE, J. A.: Ureteritis emphysematosa, spontaneous ureteral pneumogram, renal and perirenal emphysema, J. Urol. 89: 43 (1963). JENSEN, J.: Case of pneumopyonephrosis, Nord. Med. (Hospitalstid) 4: 3129 (1939). KLEIN, D. E., et al.: Renal emphysema, J. Ural. 95: 625 (1966).

UROLOGY

/

MARCH 1973

/

VOLUME I, KUMBER 3

12. LEVY, A. H., and SCHWINGER, H. N.: Gas-containing perinephric abscess, Radiology 60: 720 (1953). Spontaneous K. N., and KEATS, T. E.: 13. SESHANARAYANA, pneumopyelogram in a nondiabetic patient, Am. J. Roentgenol. Radium Ther. Nucl. Med. 107: 760 (1969). 14. STOKES, J. B., JR.: Ural. 96: 6 (1966).

Emphysematous

pyelonephritis,

J.

15. SUN, N. C.: Non-clostridial emphysematous nephritis ureteritis, cystitis and adrenalitis due to E. Coli, South.

/ MARCH1973

/ VOLUMEI,NUMBER3

C.: Emphysematgas, J. Urol. 105:

165 (1971). Pneumonephrosis, 17. WELCH, N. M., and PRATHER, G. C.: a complication of necrotizing pyelonephritis, J. Urol. 61: 712 (1949). 18. WINSTEAD, G. A.: Intrarenal gas: report of case and review of literature, ibid. 68: 423 (1952). Spontaneous renal and perirenal emphysema, 19. Yu, S. F.: Brit. J. Radiol.

Med. J. 61: 400 (1968).

UROLOCY

16. TURMAN, A. E., and RUTHERFORD, ous pyelonephritis with perinephric

39: 466 (1966).

239

Lihat lebih banyak...

Comentários

Copyright © 2017 DADOSPDF Inc.