Ibsa Daba Kumsa,Fitsum Solomon Bekele,Abeselom Lemma Gebreamlak,Nuru Bedru Hussen,Dagnachew Tamrat,Biruk Legesse Tadesse
A case report on the atypical presentation of Renal tuberculosis as emphysematous pyelonephritis
Emphysematous pyelonephritis,Renal tuberculosis,CECT scan
Introduction and importance Emphysematous pyelonephritis (EPN) is a severe acute necrotizing infection, that causes gas to build up in the collecting system, renal parenchyma, and perirenal tissues (Mahmood et al., 2020). Uncontrolled diabetes mellitus and urinary tract obstruction are the two main risk factors. We report the second case report of tuberculosis as a causative pathogen of EPN. Case presentation In this case report, a 60-year-old lady with poorly controlled type 2 diabetes was admitted to the emergency room due to left flank pain, a low-grade temperature, nausea, and vomiting. Emphysematous Pyelonephritis was diagnosed based on gas seen in the renal parenchyma on a CECT scan (EPN). She underwent conservative management, including the insertion of a nephrostomy tube and antibiotics. There is no growth detected in the nephrostomy drain's culture. She underwent a simple nephrectomy after deciding that she had not improved clinically after receiving conservative treatment. A biopsy of the specimen revealed a tuberculosis abscess. She received the proper care and made clinical progress over the course of a six-month anti-TB medication regimen. Clinical discussion The majority of EPN patients are female (2:1) and diabetic (90 %) with a mean age of presentation of 55 years (El Rahman et al., 2011). The preferred method of diagnosis for EPN is CT (El Rahman et al., 2011). E. coli, Klebsiella, and Pseudomonas were the most prevalent species in many of the reported cases (Khaira et al., 2009). In contrast to prior investigations, we discovered a case of EPN caused by tuberculosis invasion. Conclusion An essential lesson to learn from such cases is the importance of considering genitourinary tuberculosis when emphysematous pyelonephritis does not improve with conservative treatment, especially in areas with a high tuberculosis endemicity.
A case report on the atypical presentation of Renal tuberculosis as emphysematous pyelonephritis

Emphysematous pyelonephritis (EPN) is a severe acute necrotizing infection, that causes gas to build up in the collecting system, renal parenchyma, and perirenal tissues (Mahmood et al., 2020). Uncontrolled diabetes mellitus and urinary tract obstruction are the two main risk factors. We report the second case report of tuberculosis as a causative pathogen of EPN.

In this case report, a 60-year-old lady with poorly controlled type 2 diabetes was admitted to the emergency room due to left flank pain, a low-grade temperature, nausea, and vomiting. Emphysematous Pyelonephritis was diagnosed based on gas seen in the renal parenchyma on a CECT scan (EPN). She underwent conservative management, including the insertion of a nephrostomy tube and antibiotics. There is no growth detected in the nephrostomy drain's culture. She underwent a simple nephrectomy after deciding that she had not improved clinically after receiving conservative treatment. A biopsy of the specimen revealed a tuberculosis abscess. She received the proper care and made clinical progress over the course of a six-month anti-TB medication regimen.

The majority of EPN patients are female (2:1) and diabetic (90 %) with a mean age of presentation of 55 years (El Rahman et al., 2011). The preferred method of diagnosis for EPN is CT (El Rahman et al., 2011). E. coli, Klebsiella, and Pseudomonas were the most prevalent species in many of the reported cases (Khaira et al., 2009). In contrast to prior investigations, we discovered a case of EPN caused by tuberculosis invasion.

An essential lesson to learn from such cases is the importance of considering genitourinary tuberculosis when emphysematous pyelonephritis does not improve with conservative treatment, especially in areas with a high tuberculosis endemicity.

Emphysematous pyelonephritis (EPN) is a serious, acute necrotizing infection that causes gas to develop in the collecting system, renal parenchyma, and extra-renal tissues. It has a high mortality rate and is a life-threatening condition. Gas-forming bacteria, a high tissue glucose level, decreased tissue perfusion, obstruction of the urinary system, and a compromised immune response are some of the factors that may play a role in the pathogenesis of EPN [1,2]. Early identification and treatment of this entity are crucial because it has a grave prognosis. Even though EPN generally mainly affects people with diabetes mellitus (DM), it can occasionally affect people with obstructive uropathy [3]. E. coli is the most prevalent of the many bacteria involved, followed by Klebsiella, Aerobacter, Gram-negative bacilli, and mixed infections with coliforms and anaerobic streptococci [3]. Here, we present a case of emphysematous pyelonephritis (EPN), which was identified as renal tuberculosis after biopsy and was treated consequently. The patient had uncontrolled diabetes mellitus and gas in the renal parenchyma on a CT scan, and she was admitted as an emergency. A simple nephrectomy performed subject to a biopsy suggested a tuberculous abscess. These works have been reported in accordance with SCARE criteria [4]. While other etiologies of infection as a cause have been reported we could only come across a single case report of tuberculosis as a causative agent for emphysematous pyelonephritis.

We present a case. 60-year-old female patient who is a housewife and has a BMI of 28 kg/m2. She arrived at our hospital, Tikur Anbessa Specialized Hospital, via ambulance and was admitted to the emergency room with a referral for urologic intervention. When she first showed here, she had left flank pain, a low-grade temperature, nausea, and vomiting. Before being sent to our hospital, she spent four days in the ICU and was receiving IV antibiotics. She was alert and able to speak clearly, but her breathing was rapid, and she required 1–2 liter of oxygen per minute. She is a known diabetic patient for the past 8 years on vildagliptin 50 mg and metformin 500 mg PO daily with poor control. There was no history of previous treatment for pulmonary TB. On clinical examination, she was acutely sick looking and maintains her oxygen saturation with 3 L of intranasal oxygen. Her temperature was raised to 38.4 degrees Celsius. She has pale conjunctiva and has decreased air entry on the lower two the third of the lung field. Renal angle tenderness is present on the left side. On Laboratory parameters WBC: 12500 per microliter with left shift, HGB:8.1 g/dl PLT:19,500 mcL; Creatinine: 1.38 mg/dl Na: 138.3 K:0.12. A coagulation profile was done and PT: 20 s PTT: 30 s INR: 2.01 Hgba1c: 8.3 mmols. ESR was 60 mm/h. Abdominopelvic ultrasound reveals a larger left kidney with heterogeneously increased echogenicity, lack of corticomedullary differentiation, renal sinus echo reflexivity, a focal collection at the lower pole, complex per nephric collection on the same side, internal sinus and echo debris related to likely pyelonephritis, and a focal renal parenchymal collection. On CT of the abdomen and pelvis, the left kidney is enlarged and has lost its normal Reni form shape. It also appears heterogeneous, with intraparenchymal hypodense areas, fluid density fragment tissues, necrotic parenchyma, and filling defects on the left renal vein and left renal artery. Additionally, the left psoas is significantly thickened and has internal gas foci, and the left pleural fluid is also present. The conclusion is emphysematous pyelonephritis with intrarenal perinephric and psoas abscess and left renal venous thrombosis and arterial occlusion (Fig. 1). At the time of presentation, a percutaneous nephrostomy was performed, a pigtail catheter was put, under local anesthetic, with ultrasound guidance, and 200–300 ml of hemorrhagic fluid was drained, but there was no clinical improvement. Gene xpert was sent and TB was not detected. The patient's significant pleural effusion on the left side made it difficult to do open surgery and begin a long-term course of treatment. She has very poor diabetes control and a modified sliding scale with NPH (20 morning/10 evenings) with corrective measures, regular insulin started after the endocrine unit was consulted. She was started on unfractionated heparin of 17,500 in SC BID as an anticoagulant for renal vein thrombosis. Meropenem 1 g IV BID with renal adjustment dosage is initiated empirically. On The fifth day following admission, the patient is prepared for open surgery with the aid of a therapeutic pleural tap. Pleural tap and cytology were performed; they indicate hemorrhagic disease with no malignant cells found. A subcostal incision on the left flank was made to allow open access. The intraoperative discovery was a well-circumscribed mass anteriorly dark necrotic and clotted blood at per nephric tissue and adhered to the peritoneum. It is determined that the kidney is soft and not necrotic. A 200 cc sample of thick, offensive pus was taken and sent off for analysis (Fig. 2). A 16 Fr drain was left in the perinephric area after the removal of necrotic tissue and the evacuation of clots of blood. The patient continued to have persistent fever and night sweats despite taking antibiotics and receiving other treatments and continuous discharge of pus through the perinephric drain. In addition, a cystourethroscopy, a DJ stent trial was conducted and there was resistance upon stent insertion proximally suggestive of ureteric stricture. CECT is repeated and suggested (Fig. 3) that the left kidney is atrophic with a distorted shape and orientation. It is extensive per nephric heterogeneous air and fluid attenuating collection with enhancing wall and has communication with left renal collecting system and has tracked down to pelvis along with psoas muscle. There is an ipsilateral DJ stent at the proximal ureter and is kinked at mid-ureter the subcutaneous nephrostomy tube is visualized. No contrast is seen in the left renal collecting system. In conclusion, suggested for non-excretory left kidney with extensive per nephric collection having psoas extension and misplaced J stent. Due to failed conservative management, open surgery with a simple nephrectomy is done on three weeks after admission. An open approach through a left loin incision was used. Through previous incision site. Following the Left nephrectomy with ligation of the renal vessels, the kidney specimen together is sent for biopsy. A retroperitoneal drain and urethral catheter were left in situ and the patient was transferred to the ward. Postoperatively the patient a subjective complaint of the night sweating and there is 100–200 ml purulent discharge through per nephric drain for 7 days. She has also a superficial surgical site infection for which wound care was given twice daily. Culture and sensitivity from purulent drain show no growth. Biopsy result is collected and suggests a tuberculosis abscess (Fig. 4). The patient was started on Anti-tuberculosis, including rifampicin (R), isoniazid (H), ethambutol (E), and pyrazinamide (Z), for 2 months followed by a two-drug ATT regime (RH) for another 4 months. The patient is in regular follow-up in both the pulmonary and urology departments and is now asymptomatic and doing well since then. She has gained weight and improved significantly.

EPN presents most of the time in patient's e women (2:1) and diabetics (90 %) with a mean age of presentation of 55 years [3]. Michaela and co-workers reviewed 55 cases and found the left kidney to be most often involved (53 % of cases), whereas 35 % of cases involving the right kidney and 7 % had bilateral involvement [5]. The case we are reporting is a female which is 60 years with Type II diabetic patient and the pathology is also from left kidney. CT is the preferred diagnostic technique for EPN because it is well-describing the extent and the quantification of the gas and gives an idea about the destruction of the renal parenchyma. It also provides better guidance for placement of the catheter when a lot of gas is present in the area of interest, so surely it offers a conservative treatment technique for EPN in the form of percutaneous nephrostomy or drainage [3]. The expedient use of CT as opposed to ultrasound scanning in this case was invaluable. CT has 100 % sensitivity, is not operator dependent, can exclude other pathologies, and is useful to monitor response to treatment [6]. In Our case also diagnosis of Emphysematous pyelonephritis is entertained based on the CT finding which suggests extensive gas with perinephric extension. The extension of the disease to almost all the left renal parenchyma and perinephric space, the abundant gas in the retroperitoneal space, and the presence of gas in the right lower calyx classified our case as class 4 of Huang and Tseng classification [7]. The left kidney is more frequently involved than the right one. All the cases reportable far were female patients. In most of the cases reported E coli, Klebsiella and Pseudomonas were the common organisms [2]. We found a case of EPN due to, invasion of tuberculosis which was different from other studies. However, surgery is often poorly tolerated in EPN due to poor hemodynamic status secondary to associated sepsis. It has been suggested that aggressive antibiotics, percutaneous catheter drainage (PCD), and supportive therapy may be an effective alternative to nephrectomy in EPN [8]. The aggressive course of EPN and the presence of risk factors such as disturbance of hypotension, high creatinine level and indicated that our patient had a high mortality risk [3]. Despite the percutaneous management and open abscess drainage, there is no improvement in clinical response, and a Nephrectomy was done for which the biopsy result suggests a tuberculosis abscess. The patient is initiated with ant tuberculosis and responded to the anti-Tb drugs. Discharged from the ward in stable condition. Take home lesson is Tuberculosis can present as Emphysematous pyelonephritis and should be considered as differential diagnosis. The nonspecific presentation of GUTB can result in delayed diagnosis and management of the disease, which could worsen morbidity.

In high-risk groups, such, as diabetics, presenting with persistent upper urinary tract infection semiology that does not resolve with proper antibiotic treatment, the presence of a severe renal infection should be considered. Percutaneous drainage or open drainage, along with antibiotic treatment, maybe a reasonable alternative to nephrectomy. Suspecting genitourinary tuberculosis is very important in a case of emphysematous pyelonephritis. In such cases particularly in a high endemic area for tuberculosis, a therapeutic trial of anti-tubercular drugs may also be considered to avoid unnecessary surgical intervention and end-stage renal disease.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval was provided by the author's institution. Ethical review committee of the Department of Surgery, College of Health Sciences, Addis Ababa University

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1. Ibsa Daba,Kumsa MD, Urology resident: conceived, wrote and submitted the report. Operated on the patient on both surgeries. 2. Fitsum Solomon Bekele,MD(Assistant Professor of urology) operated on the patient and reviewed the case report. 3. Abeselom Lemma, MD (Assistant professor of urology):.Reviewed the case report. 4. Nuru Bedru,MD, (Urology resident): Involved in following the patient during inpatient and outpatient care. He wrote the paper and was involved in reviewing the final submission. 5. Dagnachew Tamrat,MD (Assistant professor of pathology)- Supervised and approved the specimen which is subjected for biopsy and prepared the case description of the biopsy report. 6. Biruk Legesse Tadesse,MD(Pathology resident)- Examined the specimen which is subjected for biopsy and prepared the case description of the biopsy report. 

Dr. Fitsum Solomon Bekele.

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No competing financial interests exist.