An odd cause of the lower limb restriction: Emphysematous pyelonephritis

Vigneshwar Adhithiya; Kulasekaran Nadhamuni; AM Anand; Mohamed Rafi Kathar Hussain

doi:10.4103/bjhs.bjhs_61_20

CASE REPORT

Year : 2020 | Volume : 5 | Issue : 2 | Page : 222-225

An odd cause of the lower limb restriction: Emphysematous pyelonephritis

Vigneshwar Adhithiya, Kulasekaran Nadhamuni, AM Anand, Mohamed Rafi Kathar Hussain
Department of Radiodiagnosis, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission	20-Jul-2020
Date of Decision	11-Aug-2020
Date of Acceptance	25-Aug-2020
Date of Web Publication	18-Dec-2020

Correspondence Address:
Dr. Mohamed Rafi Kathar Hussain
Department of Radiodiagnosis, Sri Manakula Vinayagar Medical College and Hospital, Puducherry
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/bjhs.bjhs_61_20

Abstract

Lower limb restriction is usually due to any pathology affecting the joints or neurological causes. Emphysematous pyelonephritis is caused by gas-producing anaerobes and is one of the life-threatening diseases. It can extend into various fascial planes can be seen causing multiple ranges of symptoms. A 49-year-old male patient came with complaints of difficulty in extending the left lower limb for the past 1 month with associated left loin pain radiating to the left lower limb. Plain CT KUB shows features suggestive of bilateral emphysematous pyelonephritis with left retro-renal multi-loculated collection with extension of infection into anterior abdominal wall fascia and inferiorly into the left pelvic muscles and left thigh. Emphysematous pyelonephritis presenting as necrotizing fasciitis is a rare phenomenon. Patients with uncontrolled diabetes can clinically present with both these entities. Necrotizing fasciitis of the thigh leading to restriction of movement in the lower limb can sometimes be the cardinal clinical and odd presentation of emphysematous pyelonephritis.

Keywords: Emphysematous, fasciitis, necrotizing, pyelonephritis

How to cite this article:
Adhithiya V, Nadhamuni K, Anand A M, Kathar Hussain MR. An odd cause of the lower limb restriction: Emphysematous pyelonephritis. BLDE Univ J Health Sci 2020;5:222-5

How to cite this URL:
Adhithiya V, Nadhamuni K, Anand A M, Kathar Hussain MR. An odd cause of the lower limb restriction: Emphysematous pyelonephritis. BLDE Univ J Health Sci [serial online] 2020 [cited 2021 Jan 24];5:222-5. Available from: https://www.bldeujournalhs.in/text.asp?2020/5/2/222/303976

Lower limb restriction is usually due to any pathology affecting the joints or neurological causes. We are presenting a rare manifestation of bilateral emphysematous pyelonephritis as the cause of restriction of the lower limb movements. Emphysematous pyelonephritis is caused by gas-producing anaerobes and is one of the life-threatening diseases. It can extend into various fascial planes can be seen causing multiple ranges of symptoms.

Case Report

A? 49-year-old male patient came with complaints of difficulty in extending the left lower limb for the past 1 month with associated left loin pain radiating to the left lower limb. He has diabetes for the past 11 years with irregular medication. He is not a known case of hypertension or thyroid disorder. There was no history of surgery or trauma in the past.

On examination, vital parameters were stable. Cardiovascular and respiratory system examinations were normal. The central nervous system examination was unremarkable. Tenderness was noted over the left lumbar region, suprapubic region, and proximal left thigh. Local examination of the left lower limb showed restricted limb movement on both flexion and extension. No atrophy of muscle was seen. The sensation was within the normal limits. The renal function test revealed a significant increase in the serum creatinine (3.5 mg/dl) and blood urea (111 mg/dl) levels. Random blood glucose was increased measuring 302 mg/dl. Urine routine examination revealed significantly increased urine sugar with plenty of pus cells. Following that, plain computerized tomography (CT) of the kidneys ureters and bladder (KUB) was requested by the urologist.

Plain CT KUB was done in 16 slice CT Philips MX16. The right kidney showed multiple small air pockets in the right renal pelvis, parenchyma, and ureter [Figure 1]. There was no perirenal collection. The right psoas and iliacus are normal-suggestive of right emphysematous pyelonephritis. (Type I). The left kidney showed multiple air pockets in the left renal pelvis, parenchyma, and ureter. Multiloculated air-fluid collection noted into perirenal space and is seen tracking inferiorly along with the psoas muscle, extending to the left iliacus and to the left anterior abdominal wall [Figure 2]. Posteriorly, it also extends to left paraspinal muscles and into the subcutaneous plane. Similar air pockets are seen extending into the left upper thigh, femoral region, and left pubic region [Figure 3]. Urinary bladder shows an air-fluid level within [Figure 4].

Figure 1: Plain computed tomography of the kidneys ureters and bladder axial section shows multiple tiny air pockets noted in the right renal pelvis and proximal ureter (arrow). A large left retrorenal multilobulated collection noted displacing the left kidney anteriorly with the presence of air pockets in the left ureter

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Figure 2: Plain computed tomography of the kidneys ureters and bladder sagittal section shows the extension of retro-renal air to the posterior subcutaneous plane in the lumbar region (arrow). Linear anterior abdominal air pockets were noted extending from the epigastric region to the pelvis. (Dotted arrow)

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Figure 3: Plain computed tomography of the kidneys ureters and bladder sagittal image shows tracking of the air from the left retrorenal collection along the left Iliopsoas into the left upper thigh (arrows)

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Figure 4: Curved coronal reconstructed image shows the presence of air pocket on the urinary bladder (arrow) and tracking of air pockets from the retrorenal collection into the left iliacus and left side pelvic muscles

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Features were suggestive of left emphysematous pyelonephritis (Class IV, Type II) with retrorenal multiloculated collection with the extension of infection into the anterior abdominal fascia and through the inferior lumbar triangle into subcutaneous plane posteriorly and extending into the left pelvic muscles and left thigh inferiorly [Figure 5] and [Figure 6]. Clinical and laboratory features are consistent with the radiological diagnosis.

Figure 5: Curved sagittal image shows multiple air pockets along the left thigh and pelvic muscles

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Figure 6: Axial section shows air pockets in the urinary bladder, pelvis, and thigh. Diffuse vascular calcification is seen, a common finding in a long-standing diabetic patient

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Discussion

Emphysematous pyelonephritis is an acute and fatal necrotizing infection of the kidneys characterized by gas formation, mostly seen in uncontrolled diabetic patients and immunocompromised individuals. Escherichia ^{More Details} coli, Proteus, and Klebsiella are the common causative organism.^[1]

Two types of emphysematous pyelonephritis have been described. Type I is more fulminant and causes extensive destruction of renal parenchyma and the presence of gas within. Type II occurs as renal/perirenal fluid collection with gas in the collecting system.^[2]

For evaluating emphysematous pyelonephritis and its types, plain CT is the imaging technique of choice. Findings include enlargement and destruction of the renal parenchyma, presence of gas, fluid collections, focal tissue inflammation and necrosis, and lastly abscess formation.^[3]

CT findings in emphysematous pyelonephritis (EPN) are classified into four classes with increasing severity. Class 1 includes the presence of gas within the collecting system only, known as emphysematous pyelitis. Class 2 includes the presence of gas in the renal parenchyma without extension into the extrarenal space. Class 3a and 3b are seen as an extension of gas/abscess into the peri and pararenal spaces. Class 4 indicates the presence of bilateral EPN or solitary renal EPN.^[4]

Necrotizing fasciitis with EPN is an uncommon presentation.^[5] Necrotizing fasciitis is defined as a progressive necrotic infection of subcutaneous tissue involving the fascia and fat with an aggressive course and has an average mortality rate of 40%.^[6]

The superior and inferior lumbar triangles are two anatomical sites of weakness in the abdominal wall as an external muscular layer is absent. Necrotizing fasciitis can occur as a complication of EPN as an extension of infection through the inferior lumbar triangle.^[7] Necrotizing fasciitis of the thigh can also be a presenting feature of EPN.

Early diagnosis and treatment of EPN improve the prognosis. Treatment of EPN is the administration of intravenous antibiotics followed by nephrectomy if indicated. As an alternative to nephrectomy, percutaneous drainage can be performed which is a kidney-saving procedure.^[8] Nowadays more urologists are opting for conservative management in the form of preservation of the kidney more than nephrectomy.^[9],[10]

In our case, there is bilateral EPN with the extension of necrotizing fasciitis of the abdomen and left thigh, which is causing restriction of the left lower limb movements. Therefore, in patients presenting with the complaints of the unilateral lower limb pain, the possible cause of EPN also had to be considered as a differential diagnosis in certain clinical scenarios.

Conclusion

EPN presenting as necrotizing fasciitis is a rare phenomenon. Patients with uncontrolled diabetes can clinically present with both these entities. CT is the primary investigation to diagnose both necrotizing fasciitis and EPN by detecting the presence of air in subcutaneous fat, fascial planes, renal parenchyma, and pelvicalyceal system. Necrotizing fasciitis of the thigh leading to restriction of movement in the lower limb can sometimes be the cardinal clinical and odd presentation of EPN.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Schrier RW. Infections of the Upper Urinary Tract. Diseases of the Kidney and Urinary Tract. Philadelphia: Lippincott, Williams & Wilkins; 2001. p. 847-69.
2.	Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: Correlation between imaging findings and clinical outcome. Radiology 1996;198:433-8.
3.	Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: A pictorial review. Radiographics 2002;22:543-61.
4.	Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805.
5.	Lin DC, Shieh GS, Tong YC. Bilateral emphysematous pyelonephritis combined with subcapsular hematoma and disseminated necrotizing fasciitis. Urol Int 2003;70:244-6.
6.	Casqueiro J, Casqueiro J, Alves C. Infections in patients with diabetes mellitus: A review of pathogenesis. Indian J Endocrinol Metab 2012;16 Suppl 1:S27-36.
7.	Yasuda T, Tani Y. Necrotizing fasciitis caused by emphysematous pyelonephritis through iliopsoas abscess. J Orthop Sci 2011;16:832-5.
8.	Tsitouridis I, Michaelides M, Sidiropoulos D, Arvanity M. Renal emphysema in diabetic patients: CT evaluation. Diagn Interv Radiol 2010;16:221-6.
9.	Laway BA, Bhat MA, Bashir MI, Ganie MA, Mir SA, Daga RA. Conservative management of emphysematous pyelonephritis. Indian J Endocrinol Metab 2012;16:303-5.
10.	Dutta D, Shivaprasad KS, Kumar M, Biswas D, Ghosh S, Mukhopadhyay P, et al. Conservative management of severe bilateral emphysematous pyelonephritis: Case series and review of literature. Indian J Endocrinol Metab 2013;17:S329-32.