We present a case in which emphysematous pyonephrosis occurred in the first trimester of a pregnancy complicated by nephrolithiasis. Emphysematous pyonephrosis is a rare and potentially fatal clinical entity but with recognition and timely intervention by multiple disciplines, a successful outcome may be obtained.
A 37-year-old African-American woman G16 P8169 presented at six weeks’ gestation with complaints of an expanding painful left flank mass. She had a seven-year history of nephrolithiasis with a course marked by frequent hospitalizations for pyelonephritis. The patient was s/p left percutaneous tube displacement four weeks prior to admission. Evaluation revealed a patient with an erythematous left flank mass extending from the iliac crest to the costovertebral angle, exuding purulent material through the skin. Vital signs on admission were: B/P 123/84, pulse 100, respiration 20, temperature 98.3°F. Pelvic ultrasound confirmed a live single intrauterine pregnancy consistent with six weeks of gestation. Abdominal CT scan revealed (Figure 1):
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• an enlarged left kidney, measuring 20 cm, with diffuse cortical thinning
• an air fluid collection in the left renal collecting system consistent with emphysematous pyonephrosis
• a bilobed perinephric fluid collection extending into the subcutaneous tissues of the left posterior abdominal wall, contiguous with the posterior spinal muscle, measuring approximately 12 cm and consistent with an abscess
• lateral to the abscess a larger air and fluid collection was noted in the subcutaneous tissues of the left posterior and lateral abdominal wall measuring 20x16x12 cm
• a 1.8-cm calculi was noted in the upper pole of the left kidney, and a 1.4-cm calcified calculi in the lower pole of the right kidney • the left and right ureters were normal
Figure 1. Abdominal CT
Blood and urine cultures were obtained, and the patient was initiated on intravenous hydration and triple antibiotic therapy consisting of Ampicillin, gentamicin and clindamycin. An emergent urology consult was obtained. The patient was taken to the operating room and, via a large flank incision, underwent an incision and drainage of the left pyonephrosis. Two-thousand milliliters of purulent material was removed, copious irrigation undertaken, and a nephrostomy tube was placed for continuous drainage. Immediate postoperative care was in the surgical intensive care unit. Two hours postad-mission, the patient was noted to have unstable vital signs: B/P 60/40, pulse 120, respirations 24, temperature 103°F. The patient was maintained on Levophed® for pressure support, intravenous fluids and antibiotic therapy. On postoperative day 2, vital signs normalized with discontinuation of supportive medications after the patient was deemed hemody-namically stable. Blood and urine cultures returned with identification of Citrobacter Freundii and Pseudomonas aeruginosa. Repeat abdominal CT scan noted residual air and high-density fluid in the collecting system of the left kidney with significant perinephric infiltration and thickening.
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On postoperative day 5, the patient underwent a cystoscope, left retrograde pyelogram and stent placement, a nephrogram and adjustment of the left percutaneous tube. These procedures improved the drainage of the left kidney. The patient was discharged on postoperative day 8. The patient did not return for postsurgical care as advised by obstet-rics/gynecology or urology at our institution.