Emphysematous Pyelonephritis presenting as acute abdomen with pneumoperitoneum: A rare presentation

Abstract

Background Emphysematous pyelonephritis (EPN) is a severe necrotising infection of renal parenchyma and has been defined for more than a century. More than 200 cases have been reported in the indexed literature comprising mainly of diabetic (90%) and immunocompromised patients. EPN is extremely rare in adults without any comorbidities. EPN is considered a very fatal disease with mortality rates as high as 50-80% without proper management. Most common presentation include fever, flank pain and pyuria, but atypical presentation has been described in a couple of cases only. We report a case who presented as acute abdomen with pneumoperitoneum. Case A 22 year old non diabetic male presented as acute abdomen with pneumoperitoneum and underwent laparotomy with drainage of pyoperitoneum. He had a DJ stent in situ on left side from a long period which had likely led to emphysematous pyelonephritis with perinephric collection. The DJ stent was removed and collection was drained percutaneously and patient recovered over 1 week. Patient was discharged after 2 weeks and now is planned for right percutaneous nephrolithotripsy. Conclusions Pneumoperitoneum can be one of the uncommon presentation of EPN. Atypical presentation of EPN such as pnemopertitoneum may be confused with bowel perforation and can lead to surgery in such cases. A delay in proper diagnosis and management may increase the morbidity & mortality rates. Computed Tomography(CT) is considered investigation of choice for diagnosis of EPN and should be considered early in doubtful cases.