Diabetic ketoacidosis presenting with emphysematous pyelonephritis Yara M. Eid ⁎ , Mona M. Abdel Salam Department of Internal Medicine, Division of Endocrinology and Metabolism, Ain-Shams University Hospitals, Abbassieh, Cairo, Egypt Received 7 August 2008; accepted 22 December 2008 Abstract Mr. A.M.A. is 28-year-old Egyptian male patient who presented to the ER with diabetic ketoacidosis (DKA) and left loin pain of 3 weeks duration. The patient had a history of hospital admission 5 months earlier because of urinary tract infection and DKA. Workup of this clinical case revealed emphysematous pyelonephritis. © 2010 Published by Elsevier Inc. Keywords: Diabetic ketoacidosis; Necrotizing infection; Urinary tract infection; Emphysematous pyelonephritis; Sympathetic pleural effusion 1. Introduction We report the case of a patient with type 1 diabetes presenting with diabetic ketoacidosis (DKA) and an indolent course of emphysematous pyelonephritis. Emphysematous pyelonephritis is a rare condition that occurs almost exclusively in patients with diabetes mellitus (DM).The first case of gas-forming renal infection was reported in 1898. Since then, more than 200 cases have been reported in the literature. 2. Case presentation Mr. A.M.A. is 28-year-old Egyptian male patient. He is a known case of type 1 DM of 8 years duration. He presented to the ER with left loin pain of 3 weeks duration. The pain was localized, stabbing in character, and not relieved with nonnarcotic analgesics. The pain was associated with fever, vomiting, frequency of micturition, and dysuria. Physical examination revealed a conscious patient with tachycardia, pallor, and temperature was 38°C. There was bilateral pedal edema and tender left renal angle. Lab revealed that he had DKA; his blood sugar was 606 mg/dl, his urine was +++ for acetone, and he had metabolic acidosis; ABG showed pH=7.18, PCO 2 =29 mmHg, PO 2 =135 mmHg, HCO 3 =10 mmol/l, Sat.=97%; and CBC showed WBCs=10×10 3 /ml, Hb=8.5 g/dl, platelets=152×10 3 /ml, serum creatinine=1.9 mg/dl, Na=118 mEq/l, K=3.0 mEq/l. The patient had a history of hospital admission 5 months earlier due to urinary tract infection (UTI) and DKA, and the condition was improved upon conventional treatment with insulin, fluids, and antibiotics. The patient was admitted to the ICU. DKA resolved, but most of the symptoms persisted including loin pain. Urine analysis revealed pus cells over 100; culture and sensitivity were done which revealed Escherichia coli and Methacillin resistant staph. aureus (MRSA) was isolated in culture upon which vancomycin was prescribed (dose adjusted according to renal function). During hospital course, the patient remained feverish with no improvement in his loin pain; in addition, the patient remained pale, and chest examination revealed stony dullness over left lung base. Chest X-ray was done and revealed moderate left-sided pleural effusion. Follow-up of laboratory investigations revealed persis- tence of UTI with pus cells over 100, anemia Hb was 8 g/dl, Journal of Diabetes and Its Complications 24 (2010) 214 – 216 WWW.JDCJOURNAL.COM Abbreviations: DKA, diabetic ketoacidosis; UTI, urinary tract infection; ABG, arterial blood gases; CBC, complete blood count; WBCs, white blood cells; Hb, hemoglobin; CT scan, computed tomography scan. ⁎ Corresponding author. Tel.: +20 24826715; fax: +20 24845647. E-mail address: yaraeid@asun.edu.eg (Y.M. Eid). 1056-8727/08/$ – see front matter © 2010 Published by Elsevier Inc. doi:10.1016/j.jdiacomp.2008.12.010