© JAPI • VOL. 52 • JUNE 2004 www.japi.org 495 Case Report Emphysematous Renal Tract Disease due to Aspergillus fumigatus M Ahmad*, KV Dakshinamurty** Abstract Emphysematous renal tract disease (ERTD) is a rare necrotizing infection of renal parenchyma and/or urinary tract caused by gas producing organisms. A case of acute emphysematous renal tract disease (ERTD) (emphysematous pyelonephritis along with emphysematous cystitis) caused by Aspergillus fumigatus in a non-diabetic patient, who did not apparently have any risk factor for fungal infection, is presented. Patient had refused for any surgical intervention. He was treated successfully with liposomal amphotericin B and 5-flucytosin and achieved complete recovery. Various causes of ERTD and available therapeutic options are discussed. © CASE REPORT A 36 years, male, not a known diabetic presented with fever, dysuria, vomiting, decreased amount of urine and left flank pain of four days duration. There was no history suggestive of obstructive lower urinary tract symptoms, diabetes, hypertension, immunosuppressive drug intake, cough, expectoration, hematuria, graveluria, pneumaturia, instrumentation in urinary tract and discharge per urethra. Clinical examination revealed ill-looking, pyrexic (100°F) and toxic adult. His pulse rate was 90/ minute. Blood pressure 118/76 mm of Hg and respiratory rate was 22 / minute. He had mild pallor and pedal edema. Abdominal examination revealed soft abdomen and tenderness over left flank. There was no mass or crepitus present. Cardiovascular, respiratory and neurological examination was unremarkable. Fundus examination was within normal limits. His hemoglobin, total and differential leukocyte count and platelet count was within normal limits. He had mild renal failure (serum creatinine 2.0 mg/dl) and metabolic acidosis. He did not have any evidence of diabetes mellitus, hepatic dysfunction or electrolyte imbalance. His urine examination revealed + proteinuria, 8-10 RBCs and 20 - 30 WBCs/HPF, there was no cast or crystal present in urine. Twenty four hours proteinuria was 0.66 gm/day. His HBsAg, Anti HCV, HIV, ANA and ANCA were negative. C3 was within normal limits. X-ray abdomen did not reveal any calculus or gas in kidneys or urinary tract. Ultrasound examination showed normal right kidney with enlarged and echogenic left kidney without any evidence of urinary tract obstruction. Computerized tomography of kidneys with oral and intravenous contrast showed normal right kidney. Left kidney was enlarged and having multiple low-density areas *Assistant Professor, Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow (UP) India; **Professor and Head, Department of Nephrology, Nizam’s Institute of Medical Sciences (NIMS) Hyderabad (AP) India. Received : 13.6.2003; Revised : 29.7.2003; Re-Revised : 11.10.2003; Accepted : 26.4.2004 I NTRODUCTION E mphysematous renal tract disease (ERTD) is a rare necrotizing infection of renal parenchyma and urinary tract caused by gas producing organisms. It is characterized by presence of gas in renal parenchyma, collecting system, perinephric tissue and urinary bladder. ERTD deserve special attention because of its life threatening potential, primarily due to sepsis and multisystem organ failure. E.coli is the commonest organism found in about 75% of patients, other organisms like Proteus, Pseudomonas, Klebsiella, Acinetobacter and Clostridium are also reported. Emphysematous pyelonephritis (EPN) caused by various fungi like Candida albicans , Candida tropicalis and Cryptococcus are also well documented. 1 ERTD arising from polycystic kidney disese and renal allograft are also reported. Aggressive surgical management either nephrectomy or nephrostomy is the treatment of choice for EPN, but successful medical management alone has been reported infrequently. 2 Our search for published literature did not reveal any report of ERTD caused by Aspergillus fumigatus. We report an unusual case of ERTD caused by Aspergillus fumigatus, which was managed successfully with antifungal therapy alone without any surgical intervention.