Necrotizing Fasciitis of Thoracic and Abdominal Wall with Emphysematous Pyelonephritis and Retroperitoneal Abscess

Abstract

Emphysematous pyelonephritis is a life-threatening severe form of pyelonephritis usually occurring in patients with diabetes mellitus with or without obstructive uropathies in whom there is necrotizing infection leading to the gas production of an unclear mechanism involving the renal parenchyma and the collecting system. Necrotizing fasciitis is characterized by progressive necrosis of fat and fascia due to deep-seated infection of subcutaneous tissue. It has a fulminant course with considerable mortality. Diabetes Mellitus is a common predisposing factor. The combined occurrence of emphysematous pyelonephritis and necrotizing fasciitis is extremely unusual. Early recognition and management is mandatory to avoid mortality. We report a case of a 53-year-old female, a known case of Type II diabetes mellitus, who presented with necrotizing fasciitis of thoracic and abdominal wall with emphysematous pyelonephritis in the left kidney with a retroperitoneal abscess.

Keywords: Diabetes mellitus; emphysematous pyelonephritis; lumbar triangle; necrotizing fasciitis; retroperitoneal abscess.

Figure 1

A 53-year-old female patient with emphysematous pyelonephritis with necrotizing fasciitis presented with breathlessness, pain in left lower hemithorax and in the left lumbar region. (a) Noncontrast axial computed tomography thorax in mediastinal window showing bilateral pleural effusion (white arrow), (b) Coronal high-resolution computed tomography window showing necrotizing fasciitis in the left lateral chest wall (black arrow).

Figure 2

A 53-year-old female patient with emphysematous pyelonephritis with necrotizing fasciitis presented with breathlessness, pain in left lower hemithorax and in the left lumbar region. Axial noncontrast computed tomography abdomen showing a well-defined hypodense abscess along anterolateral aspect of the left kidney (white arrow) with extension into perinephric space with multiple air foci within, extension of the abscess in left anterior pararenal space (curved white arrow), posterior to pancreatic body and tail, and a radio-opaque gallstone (black arrow).

Figure 3

A 53-year-old female patient with emphysematous pyelonephritis with necrotizing fasciitis presented with breathlessness, pain in left lower hemithorax and in the left lumbar region. Axial noncontrast computed tomography abdomen showing retroperitoneal abscess extending anterolateral to left psoas, anterior to left iliacus, extending up to left inguinal region with multiple air foci (white arrows). Multiple air foci just beneath anterior abdominal wall on either side, in intermuscular fat planes of abdominal wall muscles and in subcutaneous fat in anterior abdominal wall on the left side (curved white arrows).

Figure 4

A 53-year-old female patient with emphysematous pyelonephritis with necrotizing fasciitis presented with breathlessness, pain in left lower hemithorax and in the left lumbar region. Noncontrast computed tomography abdomen and pelvis (a: coronal and b: sagittal) showing left renal (white arrow) and retroperitoneal abscess with air foci (curved white arrow).

Figure 5

A 53-year-old female patient with emphysematous pyelonephritis with necrotizing fasciitis presented with breathlessness, pain in left lower hemithorax and in the left lumbar region. Noncontrast computed tomography thorax and abdomen with pelvis (a and b: mediastinal window - axial, c: coronal) showing necrotizing fasciitis in the left lateral chest wall up to left axilla (black arrow), along left lateral abdominal wall (white arrow) reaching up to perivesical fat (curved white arrow).

Figure 6

A 53-year-old female patient with emphysematous pyelonephritis with necrotizing fasciitis presented with breathlessness, pain in left lower hemithorax and in the left lumbar region. Noncontrast computed tomography abdomen and pelvis showing pigtail catheterization in a retroperitoneal abscess (white arrow).