MO098: Emphysematous Pyelonephritis in Bangladesh over a Decade, 2012–2021
Authors: Abdur Rahim Muhammad , Samad Tabassum , Mohosin Ul Haque Wasim M D 
Published: May 2022

Abstract

BACKGROUND AND AIMS
Emphysematous pyelonephritis (EPN) is an acute and severe form of necrotizing infection of the renal parenchyma, collecting system and/or perinephric tissues, and it is characterized by accumulation of gas within these anatomic locations. Common presenting features are fever, loin pain, vomiting and shock. Risk factors for EPN include diabetes mellitus (DM), renal stone, obstructive uropathy and immunosuppression. In this report, we describe the clinical, laboratory and imaging characteristics of patients with EPN in Bangladesh.

METHOD
This systematic review included all previously published English literature containing information regarding EPN in/or from Bangladesh. Literature search was conducted via ‘PubMed’ using the key words ‘Bangladesh’ and ‘emphysematous pyelonephritis’. We also searched through Bangladesh Journals Online (BanglaJOL) for articles published in local journals. The search engine ‘Google’ was also used to identify articles. All literature searches were conducted up to 31 December 2021. Unpublished, well-documented EPN cases (six cases) were added. Cases mentioned elsewhere with inadequate information and possible repetition were excluded.

RESULTS
Twenty two papers were identified from published literature (first case in January, 2012), including 11 case reports, 4 original research articles, 2 images and 5 conference abstracts, and 1 research paper was identified from other source. From them, two case reports were excluded because EPN occurred in non-Bangladeshi nationals; two images and five conference abstracts were excluded because of inadequate information for cases. Finally, a total of 13 papers (total 148 cases) were eligible for analysis, to which six unpublished but well-documented cases were added. Among the total 154 cases, females were 136 (88.3%). The age of the patients ranged between 20 and 85 years. DM was the most common risk factor (146, 94.8%) and nine (5.8%) had renal stones. Patients presented with fever (136, 88.3%), loin pain/renal angle tenderness (102, 66.2%), dysuria (79, 51.3%), altered sensorium (22, 14.3%), anorexia (93, 60.4%), vomiting (111, 72.1%), dehydration (78, 50.6%) and shock (18, 11.7%). Patients had neutrophil leucocytosis (total white cell counts 11 700–54 200/cmm of blood) and 22 (14.3%) patients had thrombocytopaenia. All patients had high erythrocyte sedimentation rate (36–117 mm/1st h) and C-reactive protein (24–199 mg/L). Overall glycaemic status was poor [random blood glucose during admission was 6.8–35.5 mmol/L and glycated haemoglobin (HbA1c) was 6.2–16.1%]. Fifty nine (38.3%) patients were complicated by acute kidney injury (AKI) and 35 (22.7%) patients had hyponatraemia. One patient had EPN in ectopic right kidney, two patients had EPN along with emphysematous cystitis and three patients were complicated by psoas abscess. According to Huang and Tseng classification, 6 (3.9%) patients had class 4 EPN, 41 (26.6%) patients had class 3, 93 (60.4%) patients had class 2 and 14 (9.1%) patients had class 1 EPN. Escherichia coli was the most common (77, 50%) organism identified on urine culture, and 23 (14.9%) patients were complicated by bacteraemia. In one patient, EPN was due to genitourinary tuberculosis. All patients were treated with resuscitative measures, intravenous antibiotics and other supportive measures. Forty four (28.6%) patients required surgery/interventions [nephrectomy in 22 (14.3%), percutaneous drainage in two (1.3%), open drainage in 20 (13%)]. The duration of hospital stay was 6–37 days. Ten (6.5%) patients died in hospital.

CONCLUSION
EPN occurred predominantly among female diabetic patients with clinical presentation of fever, loin pain, dysuria, vomiting, altered sensorium and shock. Class 2 EPN was the most common. Over one-third of all EPN cases developed AKI. Nearly one-third required surgical interventions including nephrectomy. In-hospital mortality was low, 6.5%.