Title: Simultaneous Emphysematous Pyelonephritis and Emphysematous Osteomyelitis of Spine – A Case Report and Review of Literature

1. Title: Simultaneous Emphysematous Pyelonephritis and
Emphysematous Osteomyelitis of Spine – A Case Report and
Review of Literature
Narinder Kaur (Presenting Author)*, Gurkamal Kaur**Monica Gupta*** Sanjay
D’Cruz****
*Professor & ** Senior Resident Department of Radiodiagnosis, *** and
****Professor Department of Medicine. Government Medical College and
Hospital Chandigarh, India.

2. INTRODUCTION
• Emphysematous Pyelonephritis (E.P.): is infection of kidneys by gas forming organisms and has high
morbidity and mortality.
• Emphysematous osteomyelitis (E.O.): is the infection of bones by gas forming microorganisms and
E.O. of spine is a rare and potentially fatal condition with presence of air within the bones of vertebral
column. E.O. is caused by a variety of gas-producing bacteria [1]. Only few cases of emphysematous
osteomyelitis have been reported in the literature till now[1] .Commonly involved sites are
vertebral bodies, pelvis, and lower limb bones[2]. Hematogenous spread is the commonest route
of spread to the bones, though it can also spread from adjacent infected soft tissues such as skin or
abdominal organs[2 , 4].
• Escherischia coli, Klebsiella, Enterobacter species, clostridium and other anaerobic organisms are
implicated for causing E.O.[3].
• Patients with immunocompromised status are more prone to develop emphysematous osteomyelitis [5] as well as
emphysematous pyelonepphritis.
• Both these conditions are associated with high mortality as reported in literature. Only few cases of
simultaneous emphysematous pyelonephritis and emphysematous osteomyelitis have been reported in
the literature.
We are presenting here a case of a patient having uncontrolled Diabetes mellitus and coexistent
emphysematous pyelonephritis and emphysematous osteomyelitis of spine and a brief review of literature
on this entity.

3. MATERIAL & METHODS, and INVESTIGATIONS
o Material and Methods: A 60 year old male patient, not a known diabetic & a known case of
left renal calculus, presented to medical emergency department with present complaints of:
decrease urine output for 2days, shortness of breath for 2days, vomiting for 4 days and burning
micturition for 4days. He was hospitalized immediately and subjected to following investigations:
o Investigations: Hb= 10g/L, TLC= 15.5 x 104/L, DLC: Neutrophils= 90%, Lymphocytes= 05%, Monocytes =
03% Eosinophils = 02%,
o Blood sugar random= 400mg/dl
o Blood sugar fasting = 300mg/dl
o Blood urea= 289mg/dl, Serum creatinine= 3.7mg/dl
o CPK= 15 IU/L, Sodium= 131mEq/L, Potassium= 5.4mEq/L
o Chloride= 96mEq/L, Serum albumin 2.4mg/dl
o Total proteins= 5.2mg/dl
o Total Serum bilirubin= 5.7mg/dl, conjugated Bilirubin= 4.4mg/dl, Alkaline phosphatase =357mg/dl, SGOT = 18
IU/L, SGPT= 14 IU/L:; HIV, HCV & HBs Ag negative.
Continude>>

4.  Ultrasound abdomen: showed normal
sized kidneys, bilateral increased renal parenchymal
echogenicity, moderate left hydronephrosis and
evidence of air within left kidney.
Liver and porto-systemic axis was normal, with
increased periportal echogenicity.
 Non- contrast computerized
tomography (NCCT): revealed
o Bulky left Kidney, few small air specks with
in renal parenchyma and air within the pelvi-
calyceal system and perirenal soft tissue
stranding- indicating emphysematous
pyelonephritis. No calculus was detected in
bilateral kidneys, ureters and urinary bladder.
o Air was also present within the lumbar and
sacral vertebral bodies, suggestive of
emphysematous osteomyelitis pre and
paravertebral soft tissues, retro peritoneum
and epidural and intrathecal space.
Axial non contrast CT scan at the
level of lumber region showing:
* Air within the vertebral body
and transverse processes: white
arrows,
*Air within the thecal sac: red
arrows,
*Air in the pre & paravertebral
soft tissues: yellow arrows
Axial non contrast CT image : RK-
right kidney, LK- left kidney, air
within the
left pelvi-calyceal system marked by
red arrow
RK LK
RADIOLOGICAL INVESTIGATIONS

5. A: Sagittal scan & B: Coronal scan at the level of lumbo-sacral spine
showing:
 Air within the vertebral bodies: white arrows,
 Air within the thecal sac: red arrows,
 Air in the pre & paravertebral soft tissues: yellow arrows
RADIOLOGICAL INVESTIGATIONS
A
B
RESULTS
Diagnosis:Hyperglycemia,
emphysematous- pyelonephritis, and
emphysematous osteomyelitis of spine,
along with raised serum bilirubin and
alkaline phosphatase levels. ( bilirubin and
alkaline phosphatase levels are likely
secondary to renal failure in this case).
Treatment: Patient was put on broad
spectrum intravenous antibiotics, regular Insulin
for hyperglycemic control and systemic hydration.
Unfortunately patient expired within 72 hours of
hospitalization
B

6. CONCLUSION
REFERENCES
1. Fotios-Panagiotis Tatakis P F, Kyriazis L, Panagiotopoulou E L,
Kalafatiseorgios E, Mantzikopoulos G, Polyzos K, Kachrimanidis L,
Vogiatzakis M A, Rellou S, Manta E, Tzaki M, Papaioannou V, Lelekis M.
Simultaneous Diagnosis of Emphysematous Osteomyelitis and
Emphysematous Pyelonephritis in a Diabetic Patient; e-ISSN 1941-
5923, © Am J Case Rep, 2019; 20: 1793-1796, DOI:
10.12659/AJCR.920006
2. Shruti Kumar, Mansi Verma, Vikas Bhatia, Mahesh Prakash, Lokesh
Singh. Coexistent Emphysematous Osteomyelitis and Pyelonephritis – A
Report of Two Cases. Doi: 10.25259/IJMSR_18_2019.
3. Luey C, Tooley D, Briggs S: Emphysematous osteomyelitis: A case
report and review of the literature. Int J Infect Dis, 2012; 16: e216–20
4. McDonnell O, Khaleel Z. Emphysematous osteomyelitis. JAMA Neurol
2014;71:512.
5. Lee J, Jeong CH, Lee MH, Jeong EG, Kim YJ, Kim SI, ET AL.
Emphysematous osteomyelitis due to Escheria coli. Infect Chemother.
2017; 49: 151-4 .
• Emphysematous Pyelonephritis is infection of
kidneys by gas forming organisms and has high
morbidity and mortality. Emphysematous
osteomyelitis of spine is a rare and potentially
fatal condition with presence of air within the
bones of vertebral column. This entity reminds
us one of the rare life threatening conditions
occuring in immunocompromised patient.
• Both these conditions are associated with high
mortality as reported in literature. An early
diagnosis and initiation of necessary treatment
is required in these entities to save patients.
• In our case patient died despite aggressive
systemic treatment for control of infection by
microorganisms infecting kidney and spine,
regular insulin for control of hyperglycemia and
supportive treatment.
• Role of CT scanning and
Radiologist: in such cases is to make early
diagnosis, as prompt and aggressive systemic
treatment is required for successful treatment
of such patients.
THANK YOU