Smoldering the wildfire in the kidney: A case series of emphysematous pyelonephritis

Abstract Emphysematous pyelonephritis (EPN) is a rare but rapidly progressive, potentially life-threatening infection most commonly seen in immunocompromised patients, especially with uncontrolled diabetes mellitus. It is associated with the presence of gas within renal parenchyma and surrounding perinephric tissues. Traditionally, upfront emergency nephrectomy was considered the best available treatment option due to the associated risk of high mortality. Recent advances have shown that EPN can be managed with broad-spectrum antibiotics and image-guided percutaneous drainage. These approaches can help preserve renal function and reduce the need for emergency surgery to a planned elective procedure. We present a retrospective case series of 11 patients diagnosed with EPN at a tertiary care centre in southern India. Diagnosis was established and classified as per Huang and Tseng. Management decisions were individualized based on clinical severity and imaging findings. The majority of our patients were female. Ten had diabetes mellitus, and one tested positive for a retroviral infection. The most common symptoms were flank pain and nausea. Five patients (45.5%) were treated conservatively with intravenous antibiotics and image-guided percutaneous catheter drainage (PCD). All of them fully recovered without needing surgery or experiencing any deaths. Among six patients who underwent nephrectomy, two patients who had emergency nephrectomy succumbed to their illness. Early diagnosis, proper imaging, and assessment of disease severity are crucial for guiding treatment. Emergency nephrectomy, which carries a high risk of complications and death, should be reserved for patients with more severe, refractory, or fulminant cases.