Emphysematous Pyelonephritis Masquerading as Diabetic Ketoacidosis: A Case Report

Abstract

Emphysematous pyelonephritis (EPN) is a rare, fulminant, gas-forming necrotising infection of the renal parenchyma and surrounding tissue that occurs almost exclusively in patients with diabetes mellitus and carries substantial morbidity and mortality if not recognised promptly. Diabetic ketoacidosis (DKA) is itself a recognised precipitant and consequence of severe infection in such patients, and when the two coexist the metabolic emergency can dominate the clinical picture and delay diagnosis of the underlying urological source. We report the case of a 49-year-old man with poorly controlled type 2 diabetes mellitus (glycated haemoglobin 12.8%), hypertension and heart failure with reduced ejection fraction who presented with a two-day history of left flank pain, vomiting, fever and breathlessness, and was found to be in septic shock requiring vasopressor support. Initial evaluation revealed severe leukocytosis, diabetic ketoacidosis (pH 7.27, bicarbonate 14 mmol/L, blood glucose 434 mg/dL with positive ketones), acute kidney injury and electrolyte derangement. Cross-sectional imaging confirmed left-sided emphysematous pyelonephritis with obstructive uropathy, and urine culture grew Enterobacter species. The patient was managed with intensive care support, intravenous fluid and insulin therapy, broad-spectrum antibiotics, vasopressors, and urological source control with double-J (DJ) ureteric stenting, avoiding the need for nephrectomy. He improved steadily and was discharged on basal-bolus insulin therapy with a plan for elective stent removal. This case underscores the importance of maintaining a high index of suspicion for emphysematous pyelonephritis in any diabetic patient presenting with diabetic ketoacidosis accompanied by flank pain or unexplained sepsis, and illustrates that early imaging combined with a multidisciplinary medical-urological approach can achieve renal preservation even in critically ill patients.