An 82 y.o. with temporal arteritis on steroids comes in with leg weakness.
he has air in both psoas muscles and in the renal collecting system
And air in the spinal canal; What is wrong?
Our patient had a severe infection with both pyomyositis and pyelitis. Pyelitis is an inflammation of the lining of the renal pelvis and calyces. It causes changes within the renal pelvis lining where pyelonephritis involves the main renal parenchyma. Pyelitis is usually less severe than pyelonephritis and may resolve without treatment although it can present with the same symptoms as pyelonephritis. However, emphysematous pyelitis is associated with gas in the collecting system caused by a gas forming bacteria. Our patient grew Enterobacter aerogenes from the blood and died of sepsis. Presumably a urinary tract infection and bacteremia caused his pyomyositis and pyelitis. It can be argued that the gas in the psoas represented necrotizing fasciitis but an MRI was never done to identify fascial edema.
Risk factors of pyelitis/pyelonephritis include: anatomic abnormalities of the urinary tract, vesicoureteral reflux( many children under the age of six present with infections because of this), diabetes, immune compromise, tuberculosis and obstruction (due to stones or BPH)
tuberculosis is a common cause of pyelitis/pyelonephritis world wide.
The kidneys can be infected by Mycobacteria with 20% of nonpulmonary tuberculosis involving the genitourinary tract. “Sterile pyuria” is the chief finding with GU tuberculosis. Mycobacteria can cause either a pyelonephritis, interstitial nephritis or amyloidosis . With 10 million new cases of tuberculosis yearly worldwide, the incidence of GU tuberculosis is increasing.
CLASSIFICATION OF KIDNEY INFECTION
Pyelitis- involves only the lining of the collecting system
Acute Pyelonephritis- involves the renal parenchema with interstitial abscesses and often tubular damage causing casts in the urine
Chronic pyelonephritis- results in scarring of the renal parenchyma and impaired function, infection may occur around the kidney.
Chronic pylonephritis results in a small scarred kidney
Xanthogranulomatous pyelonephritis- Is a form of chronic pyelonephritis presenting as a painful kidney mass, abscess formation and kidney destruction. Often surgical removal of the kidney is needed.
in xanthogranulomatous pyelonephritis the differentiation of the calyces is lost
Eastwood J, Corbishley C, Grange J. Tuberculosis and the Kidney. JASN June 2001,12(6)1307-1314.
Korkes F, Favoretto R, Broglio M, et al. Xanthogranulomatous pyelonephritis: clinical experience with 41 cases Urology 71(2):178-80.
Scholes D, Hooton T, Roberts P, et al. Risk factors associated with acute pyelonephritis in healthy women. Annal of Internal Medicine 142(1):20-7.
Jepson R, Williams G, Craig J. Cranberries fo preventing urinary tract infections. The Cochrane Database of systematic Reviews. 10:CD001321. Doi 10.1002/146518/////CD001321.pub5
Hiremath R, Mahesh, Padala K, et al. A rare case of pneumoureter: emphysematous pyelitis vs emphysematous pyelonephritis. J Clin diagn Res 2015 Nov;9(11):TD03-05
Seok J, W=Jee W, Chun K,et al. Necrotizing fasciitis versus pyomyositis: discrimination with using MR imaging. 2009. Korean J Radiol Mar-Apr;;10(2):121-128.