Emphysematous pyelonephritis: disappearing kidneys.

A 51-year-old man with type 2 diabetes mellitus for 10 years and hypertension for 8 years, who was a smoker and an alcoholic, presented with a history of fever, chills, and rigor of 4 days; abdominal pain and distension of 3 days; jaundice and anuria of 1 day duration. He had been binge drinking for 2 days before admission and had not taken insulin for several days. Examination revealed jaundice, tachypnea, tachycardia, a blood pressure of 90/70 mm Hg, and diffuse abdominal tenderness, with no guarding or rigidity. Investigations showed the following results: random blood glucose, 385 mg/dl; serum creatinine, 8.5 mg/dl; blood urea, 185 mg/dl; serum sodium, 142 mEq/l; serum potassium, 5.5 mEq/l; serum bilirubin, 8.0 mg/dl; hemoglobin, 13.5 g/dl; total leukocyte count, 30,800/μL; platelet count, 85,000/μL; and urine and blood cultures, sterile. Ultrasound abdomen showed multiple gas shadows in both the kidneys. Computerized tomography scan of the abdomen (Figure 1 and Supplementary Figure S1 online) revealed that the major parts of kidneys were replaced by gas, with only shreds of renal tissue visible. On the same day, bilateral ultrasound-guided percutaneous drainages were placed (Supplementary Figure S2 online). The pus revealed the growth of Escherichia coli. He was treated with pipercillin–tazobactum and aztreonam for 3 weeks. There was improvement in fever and hypotension. However, he remained dialysis dependent.