Emphysematous pyelonephritis in renal transplant recipient
Marisa Cobos1,2,3,4, Tatiana Socarras Gomez3, Mariano Massa1,2, Roberto Tanús1,2, Clemente Raimondi1,2,4.
1Cátedra de Trasplantes de Órganos y Tejidos, Facultad de Ciencias Médicas - Universidad Nacional de La Plata, La Plata, Argentina; 2Área de Trasplantes, Hospital Español de La Plata, La Plata, Argentina; 3Carrera de Especialización en Infectología, Facultad de Ciencias Médicas - Universidad Nacional de La Plata, La Plata, Argentina; 4Comisión Directiva, Fundación para el Desarrollo Integral de los Trasplantes (FuDIT), La Plata, Argentina
Introduction: Emphysematous pyelonephritis (EPN) is a necrotizing infection caharacterized by the presence of gas in the renal parenchyma, collecting system and peri- renal tissues. It´s a life threatening disease, nonspecific presentation, extremely rare in transplant recipients. Associated factors are: Diabetes mellitus, female sex, inmunosuppresion, urinary tract obstruction, and impaired vascular supply. It´s typically caused by gas producing bacteria such as Escherichia coli and Klebsiella pneumonia. We report a case of EPN in a transplant recipients.
Case Description: 63-year-old male patient with end-stage renal failure due to polycystic disease. Kidney transplant with deceased donor in December 2017.
There is no history of urinary stent, diabetes, rejection or obstruction of the urinary tract.
Urinary tract colonization with Klebsiella pneumoniae producing extended spectrum Betalactamases (BLEE).
In January 2020 consulted for deterioration of the general state, vomiting, diarrhea, anuria. TA: 100/60 FC: 120 FR: 22 SAT 89% FIO2 21%. He had no fever, urinary symptoms, graft site pain or signs of peritoneal irritation. Immunosuppression with meprednisone and mycophenolate.
Leukocytes 9100 103 / mm3, neutrophils 82%, Platelets 192000 103 / mm3, hb 7.3 g / dl. Creatinine 2.70 mg%. Urinary sediment: semi-covered leukocyte field.
Start empirical treatment with Meropenen.
Graft echodoppler without collections or urostasis, with normal arterial resistance indices.
For the first 24 hours, afebrile continues, with pain in the right hypochondrium. Ultrasound with presence of air bubbles in upper and lower calyces. Tomography with densification of the perirenal fat and presence of bubbles at the level of the renal sinus. Nephrostomy is performed.
Uroculture: Klebsiella pneumoniae BLEE, negative blood cultures, negative coproculture, negative Clostridium difficile toxin, CMV viral load <100 copies.
Patient completed 3 weeks of intravenous treatment. Continue with ertapenem.He with clinical, laboratory parameters and imaging improvement.
Discussion: Emphysematous pyelonephritis has a high mortality . Of 29 cases reviewed 93% were diabetic, the rest were observed obstructive uropathy and a case of rejection. The 58.6% required transplantectomy, 27.5% antibiotic treatment with percutaneous drainage, 13.7% antibiotic management. The 13.7% died, 44.8% entered hemodialysis and 41% recovered renal function. The predominant germ was Escherichia coli (41.3%) and Klebsiella pneumoniae (34.4%).
In our case as a only risk factor was chronic colonization by Klebsiella pneumoniae. According to the staging of Geizawi corresponded to a stage 2, so it was managed with antibiotic therapy and percutaneous drainage with favorable evolution.
For this reason we highlight the importance of knowledge of the microbiological colonization of the urinary tract for early diagnosis and targeted therapy.
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