Emphysematous Pyelitis Disguised as Cholestasis and Jaundice

Emphysematous pyelitis (EP) is a rare infection of the renal pelvis most commonly occurring in diabetics and presenting with dysuria, fever, and flank pain. It is thought to be a result of gas producing bacteria, most commonly E. coli and Klebsiella species, infecting the renal pelvis. It is differentiated from emphysematous pyelonephritis (EPN) in that the air is around the collecting system and not within it. EP carries a much better prognosis than EPN with a mortality rate of approximately 20% versus 50%, respectively. Complications include intra-renal and perinephric abscesses, spontaneous renal hemorrhage, and in the most severe cases, death. The recommended treatment is drainage of the abscess and completion of a prolonged course of antibiotics. In rare cases, EPN has been associated with mild cholestasis and hyperbilirubinemia. In these cases, it is thought that the cholestasis is related to sepsis and does not represent any obstruction of the biliary tree. In this article, we present an atypical presentation of a rare disease in an effort to increase awareness and understanding of the various clinical signs and symptoms associated with emphysematous pyelitis.

Emphysematous Pyelitis
Emphysematous Pyelitis

Our patient, a 76-year-old female, with no past medical history, presented to the emergency department with progressive weakness followed by the onset of jaundice. Other symptoms included a decreased appetite, nausea, generalized abdominal pain, diaphoresis and chills. She was afebrile and hypertensive on presentation.


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