A Case Report With Multiple Organ Abscesses And Literature Review Of Five Cases Of Emphysematous Pyelonephritis

Objective:With the prevalence rate of diabetes increasing year by year,and long-term glucose metabolic disorders existing in diabetic patients,patients' anti-infective abilities decrease with a tendency to combine multiple organ infection.A variety of infectious diseases,such as emphysematous pyelonephritis,hepatic abscess,perinephric abscess and empyema have gradually occurred in diabetic patients.As a kind of acute necrotic infectious disease,emphysematous pyelonephritis has the major features of diffuse necrosis in renal parenchyma as well as the adjacent tissue,and gas generation in renal parenchyma.It is rare,but of high mortality rate.It is indicated that 95% of patients with emphysematous pyelonephritis have diabetes,while it is rarely reported in non-diabetic patients.Besides,if blood sugar is poorly controlled in diabetic patients,deep abscess such as hepatic abscess,perinephric abscess and empyema may occur.The disease has a hidden onset that is not easy to be discovered,and it is a serious disease that is prone to septicemia,causing septic shock,multiple organ failure,or even death.In conclusion,emphysematous pyelonephritis is rare in clinical practice,and diabetics combined with multiple organ abscess,such as emphysematous pyelonephritis and hepatic abscess is even rare and of greater harm as a result of poor blood sugar control,therefore,medical workers should pay attention to it.The article reports one case of diabetics combined with multiple organ abscess,including emphysematous pyelonephritis,hepatic abscess,perinephric abscess and empyema that is received and treated in our hospital and summarize the clinical features through 5 cases of literature of emphysematous pyelonephritis with an aim to strengthen medical workers' understanding towards the above-mentioned diseases,and increase the diagnosis rate and cure rate.Methods:1.Report and analyze one case of diabetics combined with emphysematous pyelonephritis,accompanying with multiple organ abscess that is received and treated in the department of endocrinology of the second affiliated hospital of Dalian Medical University,and record its etiology,clinical manifestation,laboratory inspection,imaging examination,treatment protocols and prognosis follow-up.2.Conduct a retrospective analysis of the emphysematous pyelonephritis cases(including this case)picked out from the 1419 pyelonephritis cases from August,1991 to October,2015 in the second affiliated hospital of Dalian Medical University to summarize the clinical features.Results: There are 5 cases of emphysematous pyelonephritis,all of which are combined with diabetics,among the 1419 cases of pyelonephritis,and emphysematous pyelonephritis is not seen combined with non-diabetic patients.There are 3 male cases and 2 female cases among the 5 cases reported,with the age of onset ranging from 34 to 77 years old,and a mean age of 55.4 years old.The clinical diagnosis criteria of emphysematous pyelonephritis are as follows: imaging examination showing pyelonephritis combined with gas formation within renal parenchyma after eliminating the possibility of fistula in collective system and digestive system that are triggered by iatrogenic factors.EPN can be divided into type I and type II according to the renal parenchyma as well as the degree of pneumatosis and effusion.The 5 EPN patients in this article are of type II.There are 2 cases of nephritis on the left side,2 on the right side,and 1 on both sides among the 5 cases of emphysematous pyelonephritis,with the most commonly seen clinical manifestations being fever,chills,lumbago(4/5);and nausea and vomiting(3/5),unconsciousness(2/5),dysuria,urgency and frequency(1/5),together with upper abdominal pain(2/5)being in the second place.The major clinical sign is percussion tenderness over renal region of the affected side(4/5).All patients are combined with diabetics with a high blood sugar level,and 4 cases develop diabetic ketoacidosis(DKA).There are 2 cases accompanying with single organ abscess(perinephric abscess),and one case accompanying with multiple organ abscess,including hepatic abscess,perinephric abscess and empyema in the 3 cases that accompany with organ abscess.The total white blood cells in all 5 patients with emphysematous pyelonephritis are higher than normal,the hemoglobin in all patients are smaller than 110g/L,the platelet count in 3 cases are smaller than 100�10/L,the urine ketone bodies are positive in 4 cases,and the random venous blood sugar in all patients are greater than 20mmol/L.The results of blood culture,urine culture and puncture fluid culture are Escherichia coli-based.All patients receive abdominal CT examination upon admission to hospital,which shows increased kidney volume with heterogeneous density,obscure renal structure in which irregular gas density can be seen,and subcapsular effusion.There is one case showing combined polycystic kidney on CT.All patients receive venous transfusion or insulin pump in small dose to control blood sugar,and a great amount of fluid infusion to rectify acid-base balance or electrolyte disturbances.All patients employ antibiotics for anti-infection,among which 3 use imipenem/ cilastatin,2 use cefoperazone,meanwhile,all patients receive renal puncture drainage,and 3 cases survive and 2 die.Conclusions: Diabetic patients are prone to combine infectious diseases,especially in the case of not being diagnosed or poor blood sugar control.Emphysematous pyelonephritis is a kind of acute necrotic disease that is characteristic of diffuse necrosis and gas formation in renal parenchyma as well as in adjacent tissue.Emphysematous pyelonephritis is commonly seen in diabetic patients.In the past,the majority of patients with emphysematous pyelonephritis would receive nephrectomy in early stage after diagnosis.Now with the development of diagnostic techniques as well as the understanding of clinical worker towards the disease,conservative medical treatment and percutaneous puncture drainage under ultrasound guidance could cure the disease if it is discovered in time.When the condition does not improve,nephrectomy would be offered.Diabetics combined with emphysematous pyelonephritis are not easily seen,and diabetics accompanying with multiple organ abscess are even rare.The atypical symptoms of the disease which offers a high mortality rate if it is not treated in time,are likely to be misdiagnosed,therefore,attention should be paid in clinical practice.