doi:10.1016/j.jemermed.2007.11.071 Visual Diagnosis in Emergency Medicine EMPHYSEMATOUS PYELONEPHRITIS WITH EMPHYSEMATOUS PANCREATITIS Kushaljit Singh Sodhi, MD,* Anupam Lal, MD,* Sameer Vyas, MD,* S. Verma, MD,† and N. Khandelwal, MD, DNB, FICR* *Department of Radiodiagnosis and †Department of Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India Reprint Address: Kushaljit Singh Sodhi, MD, Department of Radiodiagnosis, PGIMER, Chandigarh 160012, India INTRODUCTION Emphysematous pyelonephritis (EPN) is a rare, fulminant gas-forming infection of the renal parenchyma that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue (1). EPN occurs typically ( 90%) in diabetic patients. However, it is also seen in non-diabetic patients with obstruction of the renal or ure- teric system (2). Diagnosis of EPN is based on radiological confirmation of gas within the kidney or collecting system. It has a high mortality rate and needs early emergency management. Milder forms of the disease are managed successfully with a combination of antibiotics and percuta- neous drainage. However, early nephrectomy is recom- mended in more severe cases or in patients with septic shock. Our case was unusual in that there was involvement of both kidneys and the pancreas, resulting in emphysema- tous pyelonephritis and pancreatitis. CASE REPORT A 55-year-old woman who had type 2 diabetes mellitus (DM) for the past 4 years presented with a 2-week history of fever and left-sided abdominal pain. Fever was high, intermittent, and without any chills/rigor. She had pain in the left lumbar and flank region, which was associated with swelling. There was no history of trauma. Clinical examination revealed tenderness and mild swelling in the left lumbar region. She had a pulse rate of 128 beats/min, respiratory rate 36 breaths/min, and blood pressure 130/90 mm Hg. Laboratory investigation re- vealed: blood urea 40 mg%, serum creatinine 1.2 mg%, bilirubin (0.7 mg), serum glutamic oxaloacetic transam- inase (15 IU), and serum glutamic pyruvic transaminase (14 IU), all of which were within normal limits. Blood glucose levels were 204 mg%. Blood culture showed growth of Escherichia coli. Computed tomography (CT) scan of the abdomen was done, which showed a large gaseous collection (Figures 1, 2) replacing the left kidney, with minimal fluid present in the left renal fossa and perinephric space. The fluid extended inferiorly to the left hemi-pelvis and iliac fossa and superiorly was seen to extend to the anterior para- renal space, with involvement of the pancreatic body and tail as well. It was seen to involve the anterior, posterior, and lateral abdominal walls, with extensive subcutaneous air pockets in the muscles. The right kidney was normal. Based on the CT scan, a diagnosis of extensive emphy- sematous pyelonephritis with emphysematous pancreati- tis was made. The patient was treated with intravenous saline, Ami- kacin (aminoglycoside antibiotic), Oframax (ceftriaxone sodium), Metrogyl (metronidazole), and regular insulin. Subsequently, she underwent pigtail catheter drainage. She became afebrile, with controlled glucose levels un- der further observation. RECEIVED: 12 January 2007; FINAL SUBMISSION RECEIVED: 29 June 2007; ACCEPTED: 8 November 2007 The Journal of Emergency Medicine, Vol. 39, No. 1, pp. e85– e87, 2010 Copyright © 2010 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter e85