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Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 272-274

Emphysematous pyelonephritis within a horseshoe kidney

Department of Urology, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Kim Jacob Mammen
Department of Urology, Christian Medical College, Ludhiana - 141 008, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_24_17

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Association of emphysematous pyelonephritis (EPN) with horseshoe kidney is rare. It is a life-threatening condition with variable mortality. Historically, the treatment consisted of early nephrectomy. One such patient managed conservatively by placement of percutaneous drainage (PCD) and appropriate antibiotic coverage, is reported. This patient responded well to the conservative approach of treatment by insertion of PCD under computed tomography guidance. Hence, insertion of PCDs is an effective way of treating EPN.

Keywords: Emphysematous, horseshoe kidney, pyelonephritis

How to cite this article:
Tuli A, Singh F, Mammen KJ. Emphysematous pyelonephritis within a horseshoe kidney. CHRISMED J Health Res 2017;4:272-4

How to cite this URL:
Tuli A, Singh F, Mammen KJ. Emphysematous pyelonephritis within a horseshoe kidney. CHRISMED J Health Res [serial online] 2017 [cited 2020 Jan 28];4:272-4. Available from: http://www.cjhr.org/text.asp?2017/4/4/272/216468

  Introduction Top

Horseshoe kidney is a pair of ectopic kidneys that are fused at their lower pole; the junction lies in front of the fourth lumbar vertebra. The fibrous isthmus of fused renal tissue encroaches on the inferior mesenteric artery, preventing further ascent of the kidneys. Horseshoe kidney is found in 1:400 births and is more common in men.[1],[2]

Emphysematous pyelonephritis (EPN) is a life-threatening acute bacterial infection of the kidney with a mortality rate of 40%–90%. It is a rare observation when associated with horseshoe kidney.[2] According to recent reports, percutaneous drainage (PCD) is effective to treat EPN and nephrectomy could be avoided in most cases.[3] Herein, we report a 42-year-old diabetic patient with EPN in a horseshoe kidney, which was managed by PCD under computed tomography (CT) guidance.

  Case Report Top

A 42-year-old female with diabetes mellitus for 15 years presented to the emergency department with vomiting, pain abdomen, fever, and intermittent hematuria for 25 days; generalized abdominal distension for 14 days along with dysuria.

On examination, she was conscious and well oriented. The vital signs included a pulse rate of 108/min; respiratory rate of 32/min; blood pressure of 110/70 mm of Hg; afebrile. There were generalized distention and tenderness of the abdomen. A ballotable retroperitoneal mass was felt in the right lumbar region.

Contrast enhanced CT abdomen showed, horseshoe kidney with right EPN with a collection of air and fluid in the right kidney, isthmus, and extending on to the perirenal space [Figure 1] and [Figure 2].
Figure 1: Noncontrast computed tomography showing air in the right kidney with a horseshoe anomaly

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Figure 2: Contrast enhanced computed tomography showing air in the right kidney with a horseshoe anomaly

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All biochemical renal parameters (blood urea, serum creatinine, and electrolytes) were within normal limits. Arterial blood gas report showed metabolic alkalosis.


She was initiated on broad-spectrum antibiotics.

A PCD was placed under CT guidance and was positioned in the area of air and fluid collection in the right kidney. Following the procedure, over a period the volume of the collection gradually decreased. Follow-up ultrasound imaging revealed a residual collection near the lower pole of the right kidney and a second PCD was inserted under CT guidance [Figure 3]. The pus culture grew  Escherichia More Details coli. The antibiotic therapy was appropriately amended as per the culture sensitivity report.
Figure 3: Patient with two percutaneous drainages placed on the right loin

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The general condition of the patient improved gradually, and nephrectomy was avoided.

Follow-up ultrasound imaging after 2 weeks showed neither any residual air nor any fluid collection. PCD was taken out. The diethylene triamine pentaacetic acid scan revealed glomerular filtration rate of 19 ml/min on the right side and 17 ml/min on the left side.

  Discussion Top

Horseshoe kidneys are prone to become infected, possibly because the ureters are angulated as they pass over the fused isthmus.[1] Such a kidney is also associated with increased risk of stone formation and renal tumors.[2]

Diabetes mellitus is reported in 85%–95% of the patients and a urinary tract obstruction is noted in 25%–60% of the cases due to stones, strictures, or aberrant vessels.[3],[4]

The presence of gas-forming organisms (most commonly E. coli [70% of cases] followed by Klebsiella [10% of cases]), a high tissue glucose concentration and impaired tissue perfusion are all risk factors for the development of emphysematous infections of the urinary tract. A high glucose concentration leads to the formation of carbon dioxide by fermentation. However, for nondiabetic patients fermentation of urinary albumin might be the cause of gas production.[3]

There are two types of EPN – Type 1 involves renal parenchyma with no renal or perinephric fluid collections, and Type 2 involves renal parenchyma with renal or perinephric fluid collections.[4]

Clinical presentation of EPN ranges from patients having minimal lower urinary tract symptoms to severe sepsis. Symptoms such as fever, chills, flank pain, lethargy, and confusion may be experienced.[3],[4] Diabetics may present with hyperglycemia, acidosis, dehydration, and electrolyte imbalances.[4]

Imaging studies are not routinely recommended for diagnosing acute pyelonephritis. However, imaging studies are necessary, when the condition is associated with a horseshoe kidney in which unusual location of pain might lead to incorrect diagnosis. CT is the most effective radiological examination to confirm the diagnosis; it shows a horseshoe kidney with intrarenal gas, with or without extension to perinephric area and parenchymal destruction.[3],[5]

EPN is associated with poor prognosis (Type 1 [33%] and Type 2 [66%]).[4]

As EPN is a severe infection, historically, the treatment consisted of early nephrectomy with antibiotic therapy. However, according to recent reports PCD along with treatment of precipitating factors can be effective to treat EPN.[3],[4] It has been shown that after PCD of EPN only 13% of patients required nephrectomy for nonfunctioning kidneys.[3]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Williams NS, Bailey H, Bulstrode CJ, Love RM, O'Connell PR. The kidneys and ureters. Bailey & Love's Short Practice of Surgery. 26th ed. Boca Raton FL: CRC Press; 2013. p. 1282-3.  Back to cited text no. 1
Sriramnaveen P, Sridhar A, Sandeep Y, Kishore CK, Manjusha Y, Sivakumar V. Acute kidney injury due to emphysematous pyelonephritis on a horseshoe kidney. Ren Fail 2011;33:730-1.  Back to cited text no. 2
Gargouri MM, Boulma R, Kallel Y, Chelif M, Rhouma SB, Nouira Y. Conservative management of emphysematous pyelonephritis in a horseshoe kidney. Afr J Urol 2014;20:88-90.  Back to cited text no. 3
Brown JA, Maharaj P, Khan O, Sinanan A. A rare case of emphysematous pyelonephritis within a horseshoe kidney. West Indian Med J 2011;60:229-31.  Back to cited text no. 4
Kim HA, Chung DR. Acute pyelonephritis in a horseshoe kidney. Korean J Intern Med 2013;28:262.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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