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Abdominal aortic aneurysm and gas in the kidney in a diabetes patient

  • Yueming Liu
    Affiliations
    Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, PR China

    People's Hospital of Hangzhou Medical College, Hangzhou, PR China
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  • Mian Ren
    Affiliations
    Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, PR China

    People's Hospital of Hangzhou Medical College, Hangzhou, PR China
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  • Yicheng Huang
    Correspondence
    Corresponding author at: Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, Zhejiang, China, 310014.
    Affiliations
    Department of Infectious Diseases, Zhejiang Provincial People's Hospital, Hangzhou, PR China

    People's Hospital of Hangzhou Medical College, Hangzhou, PR China
    Search for articles by this author
Published:January 10, 2022DOI:https://doi.org/10.1016/j.ejim.2022.01.001

      1. Case description

      A 65-year-old man was admitted to our emergency department with a 12-day history of nausea and a progressive backache, and an 8-day history of dysuria with low-grade fever. He had been diagnosed with diabetes mellitus 20 years previously, and had a history of poor glycemic control.
      On physical examination, he had a body temperature of 37.3 °C, a blood pressure of 72/43 mmHg, a bilateral wheeze on auscultation, left abdominal tenderness without rebound pain, and right renal percussion pain. Blood tests revealed a hemoglobin A1c of 12.4%, leukocyte count of 8.29 × 109 cells/L with an elevated neutrophil proportion, and a raised C-reactive protein level (119.9 mg/L). Urine examination revealed pyuria, hematuria, and glycosuria. An abdominal computerized tomography scan (Fig. 1A) revealed pneumoperitoneum, air in the retroperitoneal cavity, left perirenal pneumatosis and exudation, bilateral renal calculi, and suspicious abdominal aortic aneurysm (AAA). CT angiography of abdominal aorta (Fig. 1B) confirm the diagnosis of AAA, atherosclerosis, and a hemorrhage of the margin of his left psoas major.
      Fig. 1:
      Fig. 1Salmonella enteritidis causing emphysematous pyelonephritis and infectious abdominal aortic aneurism in a diabetes patient. An abdominal CT shows extensive gas collection in the parenchyma and perinephric space of the left kidney (blue arrows) and aneurysm in abdominal aorta (red arrow) (A). A CTA shows aneurysm formation in abdominal aorta. (B). The volume of abdominal gas decreased but aneurysm progressively increased in size (red arrow) (C).
      What is the diagnosis?

      2. Discussion section

      We performed ultrasound-guided left perinephric puncture. The drainage fluid and blood culture were both positive for Salmonella enteritidis, but his urine culture was negative. Patient was diagnosed with salmonella aortitis and emphysematous pyelonephritis (EPN). We treated the patient with intravenous ceftazidime, 2 g eight-hourly. After completing a course of antibiotic treatment, his symptoms and inflammatory markers improved, and the volume of abdominal gas decreased, but his AAA had progressed (Fig. 1C). He was transferred back to the local hospital and died 3 days later.
      Although many microorganisms, such as syphilis, Staphylococcal species, and Candida, can cause infectious aortitis. Salmonella species account for up to 40% of all infective aortitis [
      • Gardini G.
      • Zanotti P.
      • Pucci A.
      • Tomasoni L.
      • Caligaris S.
      • Paro B.
      • et al.
      Non-typhoidal Salmonella aortitis.
      ] and it's usually life-threatening. Diabetes with poor glycemic control, old age and male gender are all risk factor for salmonella aortitis [
      • Gardini G.
      • Zanotti P.
      • Pucci A.
      • Tomasoni L.
      • Caligaris S.
      • Paro B.
      • et al.
      Non-typhoidal Salmonella aortitis.
      ].
      EPN is a gas-forming, necrotizing infection of the renal parenchyma and perirenal tissue which is with high mortality and morbidity. Poorly controlled diabetes and urinary tract obstruction are major risk factors of EPN. Escherichia coli and K pneumoniae account for most cases, but other gas-producing pathogens have also been reported as the causative microorganisms [
      • Huang J.J.
      • Tseng C.C.
      Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis.
      ].
      The CT scan is sensitive to diagnosis Infectious aortitis and EPN, and subsequent guiding therapy. Standard treatments include microbiology-guided systemic antibiotic therapy, percutaneous drainage, and extra-anatomic bypass grafting or in situ reconstruction with prosthetic graft or allograft [
      • Wu H.Y.
      • Kan C.D.
      Images in cardiovascular medicine: emphysematous aortitis.
      ].

      Disclosure

      The authors declare that they have no relevant financial interests.
      Mian Ren and Yueming Liu contributed equally to this work as co-first authors.

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