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Sonographic Diagnosis of Emphysematous

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Sonographic Diagnosis of Emphysematous

4

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taufikoling
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P I C T O R I A L Sonographic diagnosis of emphysematous

M E D I C I N E
pyelonephritis in a clinically stable patient

A 39-year-old woman presented to our hospital present with a fulminant clinical picture of sepsis,
complaining of fever, polyuria and repeated vomiting relatively mild symptoms can be encountered. Our
for several days. She had no relevant medical history patient was in a stable condition with symptoms
and had been in good health. A urinalysis found suggesting a urinary tract infection. Ultrasound is
haematuria and proteinuria, and blood cultures usually the first imaging investigation to be requested
grew Gram-negative rods. An abdominal ultrasound because of its simplicity, high diagnostic accuracy,
examination found a normal-looking liver and a right and lack of radiation. Detection of renal parenchymal
kidney with large amounts of non-dependent, high gas on ultrasound requires a high index of suspicion
amplitude echoes with ‘dirty’ shadowing within the and the recognition of echogenic foci with ‘dirty’
renal parenchyma (Fig 1). This appearance was highly shadowing in a non-dependent position.3,4 The
suggestive of air inside the kidney. No renal mass or appearance can also change with patient posture.
stone was seen and there was no perinephric fluid It should be differentiated from renal stones, which
collection. Further examination showed an extension are echogenic but have clean shadows, and from gas
of pockets of air to the subcapsular region (Fig 2). within a renal abscess. Gas can be present inside
Emphysematous pyelonephritis was diagnosed the collecting system in emphysematous pyelitis,5
on the basis of these images.1,2 A non-enhanced a condition with a more benign clinical course. In
computed tomographic examination of the abdomen our patient, the clear depiction of gas inside the
was then performed, confirming that there was gas renal parenchyma with extension to the subcapsular
inside the renal parenchyma and renal pelvis (Fig surface confirmed the diagnosis.
3). The patient responded poorly to antibiotics and
required removal of her right kidney. She recovered
SY Hui, BSc, RDMS
from surgery uneventfully. Email: [email protected]
CW Cheung, MRCP, FHKAM (Radiology)
KT Hui, MB, BS, FRCR
Discussion HL She, MB, BS
Emphysematous pyelonephritis is a rare but life- Department of Radiology
threatening necrotising infection of the kidney Queen Mary Hospital
caused by gas-forming bacteria. Although it can Pokfulam Road, Hong Kong

FIG 1. Longitudinal scan of the right kidney FIG 2. Transverse scan of the right kidney FIG 3. Axial non-enhanced computed
showing echogenic foci of air (arrow) inside the showing crescent-shaped echogenicity tomographic scan of the kidneys showing right
renal parenchyma. Note the ‘dirty’ shadow (*) compatible with subcapsular air (arrows) renal enlargement and presence of air in the renal
parenchyma (arrow) and renal pelvis (arrowhead)
References
1. Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review.
Radiographics 2002;22:543-61.
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. Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic-pathologic review. Radiographics 2008;28:255-77.
4. Allen HA 3rd, Walsh JW, Brewer WH, Vick CW, Haynes JW. Sonography of emphysematous pyelonephritis. J Ultrasound Med
1984;3:533-7.
5. Roy C, Pfleger DD, Tuchmann CM, Lang HH, Saussine CC, Jacq min D. Emphysematous pyelitis: findings in five patients.
Radiology 2001;218:647-50.

Hong Kong Med J Vol 16 No 4 # August 2010 # www.hkmj.org 319

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