Endgames Picture quiz

Unwell man with abdominal pain

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1635 (Published 14 May 2009) Cite this as: BMJ 2009;338:b1635
  1. R J Currie, radiology registrar,
  2. A Watkinson, consultant radiologist
  1. 1Radiology Department, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW
  1. Correspondence to: R J Currie r.currie{at}nhs.net

    An 80 year old man with diabetes presented to the accident and emergency department on New Year’s Eve with acute onset abdominal pain. He was tachycardic and hypotensive, and had lactic acidosis. Ruptured abdominal aortic aneurysm was suspected. Given that the patient was stable, an urgent computed tomography with intravenous contrast was performed, the results of which are shown as an axial image (fig 1).

    Fig 1 Axial contrast enhanced computed tomogram of a patient with acute onset abdominal pain


    • 1 What is the salient finding on the computed tomogram?

    • 2 What is the diagnosis?

    • 3 What predisposes to this condition?


    Short answers

    • 1 The computed tomogram shows an enlarged left kidney with streaks, which indicate bubbles of gas within the renal parenchyma and perirenal spaces (fig 2). Fluid has collected in the perirenal spaces, in keeping with abscess formation.

    Fig 2 Axial contrast enhanced computed tomogram showing an enlarged left kidney (small arrow) and gas within the renal parenchyma (large arrow)

    • 2 The image findings are characteristic of emphysematous pyelonephritis within the left kidney. This disorder is a form of fulminating acute necrotic pyelonephritis. The culprit causative organisms for the condition are Escherichia coli, Proteus species, and Candida albicans.

    • 3 Diabetes is the key predisposing factor for emphysematous pyelonephritis. Other risk factors include a compromised immune system and an obstructed kidney.

    Long answers

    1 Salient findings

    Emphysematous pyelonephritis is a fulminating acute necrotic pyelonephritis characterised by gas …

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