Emphysematous pyelonephritis class IV

A 56-year-old man presented to the emergency room with diffuse abdominal pain, distention, hyperthermia, and macroscopic hematuria over the last 7 days which had been treated with gentamicin and NSAIDs (ketorolac) without clinical improvement. His past medical history was significant for poorly controlled type II diabetes mellitus and arterial hypertension. On physical examination costovertebral angle tenderness was present. Laboratory results demonstrated leukocytosis, hyperglycemia, and metabolic acidosis. Urinalysis showed red blood cell casts and bacteriuria. CT scan in coronal sectioning was relevant for presence of gas in the renal parenchyma and the kidney pelvis (Fig. 1). The patient was diagnosed with emphysematous pyelonephritis class IV according to the Huang–Tseng classification and septic shock. He was transferred to the intensive care unit where broad-spectrum empiric antibiotic treatment was started with meropenem, with favorable clinical response. The blood cultures reported back extended-spectrum beta-lactamase (ESBL)-producing E. coli.

Fig. 1

CT scan in coronal sectioning. Arrow gas in the parenchyma and the kidney pelvis