Emphysematous pyelonephritis as a complication of staghorn calculi: A case report

Introduction: Emphysematous pyelonephritis is an infection with a high mortality rate, so having a high index of clinical suspicion is important to achieve a timely diagnosis and treatment. Case presentation: This is the case of a 47-year-old woman with diabetes mellitus, high blood pressure, chronic kidney disease, hypothyroidism and a history of recurrent acute pyelonephritis who was referred to a tertiary care hospital in Lima, Peru, due to colicky abdominal pain, tachycardia, fever, and chills. Leukocytosis, moderate anemia, leukocyturia and hyperlactacidemia were evidenced in the admission laboratory tests. In addition, a renal ultrasound showed staghorn calculi in the right kidney, while visualization of the left kidney was not possible, so she was hospitalized and antibiotic therapy with ceftriaxone was started. However, four days later, and despite the antibiotic therapy, the patient presented low blood pressure, leading to discontinuation of ceftriaxone, initiation of antibiotic therapy with meropenem-vancomycin and vasopressor therapy, and transfer to the critical care unit. The next day, due to the presence of intermittent fever, hypoactive delirium, persistent hypoglycemia and oligoanuria with purulent urine, a computerized tomography urogram was performed, which revealed bilateral staghorn calculi with presence of gas and air-fluid levels in the left kidney. Considering these findings, as well as her poor clinical condition, left nephrectomy was performed, achieving favorable clinical progress. The patient was discharged 7 days after the procedure. Conclusion: Emphysematous pyelonephritis should always be suspected in women with diabetes mellitus (and irregular adherence to treatment), poor response to antibiotic therapy, and staghorn calculi. Computed axial tomography allows reaching the diagnosis and determining prognosis, therefore, an appropriate treatment can be established.