Emphysematous pyelonephritis: no longer a surgical disease?

Emphysematous pyelonephritis is a rare, life-threatening infection of the kidney characterized by the presence of gas within the renal parenchyma, the renal collecting system and the perinephric tissue. It usually develops in diabetic patients and often presents abruptly with bacteraemia, septic shock and acute renal failure. Diagnosis can be delayed because the symptoms mimic a classical upper urinary tract infection. Aggressive management, including parenteral antibiotic therapy, treatment of septic shock and control of the glycaemia, is mandatory. Immediate nephrectomy has been considered to be essential to increase the chance of survival. Recently, percutaneous drainage has been reported as a kidney-saving and life-saving alternative to surgery. We present a case of severe emphysematous pyelonephritis in which there was full recovery after antibiotic treatment combined with temporary percutaneous drainage. The therapeutic options in this rare, life-threatening condition are discussed.