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      Complicated urinary tract infections associated with diabetes mellitus: Pathogenesis, diagnosis and management

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          Abstract

          Diabetes mellitus has a number of long-term effects on the genitourinary system. These effects predispose to bacterial urinary tract infections (UTIs) in the patient with diabetes mellitus. Complicated UTIs are also common and potentially life-threatening conditions. They include emphysematous pyelonephritis, emphysematous pyelitis/cystitis, xanthogranulomatous pyelonephritis, renal/perirenal abscess, and renal papillary necrosis. Improved outcomes of these entities may be achieved by early diagnosis, knowledge of common predisposing factors, appropriate clinical and radiological assessment, and prompt management. Herein we review complicated UTIs associated with diabetes mellitus in terms of pathogenesis, clinical manifestations, radiological features, and current management options.

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          Most cited references 24

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          Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis.

          Emphysematous pyelonephritis (EPN) is a rare, severe gas-forming infection of renal parenchyma and its surrounding areas. The radiological classification and adequate therapeutic regimen are controversial and the prognostic factors and pathogenesis remain uncertain. To elucidate the clinical features, radiological classification, and prognostic factors of EPN; to compare the modalities of management (ie, antibiotic treatment alone, percutaneous catheter drainage combined with antibiotic treatment, or nephrectomy) and outcome among the various radiological classes of EPN; and to clarify the gas-forming mechanism and pathogenesis of EPN by gas analysis and pathological findings. Forty-eight EPN cases from our institution were enrolled between August 1,1989, and November 30, 1997. According to the radiological findings on computed tomographic scan, they were classified into the following classes: (1) class 1: gas in the collecting system only; (2) class 2: gas in the renal parenchyma without extension to extrarenal space; (3) class 3A: extension of gas or abscess to perinephric space; class 3B: extension of gas or abscess to pararenal space; and (4) class 4: bilateral EPN or solitary kidney with EPN. The clinical manifestations, management, and outcome were compared. The gas contents of specimens from 6 patients were analyzed. The pathological findings from 8 patients who received nephrectomy were reviewed. The statistical methods consisted of the Fisher exact test (2 tailed) for categorical variables and Wilcoxon rank sum test for continuous variables to test the predictors of poor prognosis. Forty-six patients (96%) had diabetes mellitus, and 10 (22%) of the 46 also had urinary tract obstruction in the corresponding renoureteral unit. The other 2 nondiabetic patients (4%) had severe hydronephrosis. Twenty-one (72%) of the 29 patients with diabetes mellitus also had a glycosylated hemoglobin A(1c) level higher than 0.08. Escherichia coli (69%) and Klebsiella pneumoniae (29%) were the most common pathogens. The mortality rate in patients who received antibiotic treatment alone was 40% (2 of 5 patients). The success rate of management by percutaneous catheter drainage (PCD) combined with antibiotic treatment was 66% (27 of 41 patients). In classes 1 and 2 EPN, all the patients who were treated using a PCD or ureteral catheter combined with antibiotic treatment survived. In extensive EPN (classes 3 and 4), 17 (85%) of the 20 patients with fewer than 2 risk factors (ie, thrombocytopenia, acute renal function impairment, disturbance of consciousness, or shock) were successfully treated using PCD combined with antibiotic treatment; and the patients with 2 or more risk factors had a significantly higher failure rate than those with no or only 1 risk factors (92% vs 15%, P<.001). Eight of the 14 patients who had an unsuccessful treatment using a PCD underwent subsequent nephrectomy, 7 of whom survived. Only 2 patients were managed by direct nephrectomy and survived. The overall success rate of nephrectomy was 90% (9 of 10 patients). The total mortality was 18.8% (9 of 48 patients). Five of the 6 gas samples contained hydrogen (average, 12.8%), and all had carbon dioxide (average, 14.4%). The pathological findings from 8 of 10 who underwent nephrectomy revealed poor perfusion in most cases (ie, infarction, 5 patients; vascular thrombosis, 3 patients; and arteriosclerosis and/or glomerulosclerosis, 4 patients). Acute renal infection with E coli or K pneumoniae in patients with diabetes mellitus and/or urinary tract obstruction is the cornerstone for the development of EPN. Mixed acid fermentation of glucose by Enterobacteriaceae is the major pathway of gas formation. For localized EPN (classes 1 and 2), PCD combined with antibiotic treatment can provide a good outcome. (ABSTRACT TRUNCATED)
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            Emphysematous cystitis: a review of 135 cases.

            To review recently published data on emphysematous cystitis (EC), a potentially life-threatening condition characterized by air within the bladder wall, and that most typically affects middle-aged diabetic women. All articles published in English between 1956 and 2006 were identified using a Medline search for keywords "emphysematous cystitis", and "cystitis emphysematosa." Epidemiological, clinical, diagnostic, pathological and therapeutic data were evaluated, including risk factors such as the presence of diabetes mellitus or other comorbid emphysematous infections of the urinary tract. In all, 102 published papers, including 135 cases of EC, were reviewed; the median patient age was 66 years, 64% were women and 67% had diabetes mellitus. Most cases were diagnosed using plain films of the abdomen (84%), although more recently, computed tomography was the primary imaging method. Escherichia coli was the most commonly isolated organism. Most patients were treated with medical management alone (90%), while 10% of infections were treated with a combination of medicine and surgery. The overall death rate was 7%. EC is the most common and typically the least severe gas-forming infection of the urinary tract. Prompt diagnosis and treatment is warranted to prevent the potential morbidity and mortality of this infectious condition.
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              Emphysematous infections of the abdomen and pelvis: a pictorial review.

              Emphysematous (gas-forming) infections of the abdomen and pelvis represent potentially life-threatening conditions that require aggressive medical and often surgical management. The initial clinical manifestation of these entities may be insidious, but rapid progression to sepsis will occur in the absence of early therapeutic intervention. Conventional radiography and ultrasonography are often the initial imaging modalities used to evaluate patients with abdominopelvic complaints. However, when a differential diagnosis remains, or if further localization or confirmation of tentative findings is needed, computed tomography (CT) should be considered the imaging modality of choice. CT is both highly sensitive and specific in the detection of abnormal gas and well suited to reliable depiction of the anatomic location and extent of the gas. Of equal importance may be the capability of CT to help reliably identify benign sources of gas, because treatment (if any) varies dramatically depending on the source. Knowledge of the pathophysiologic characteristics, common predisposing conditions, and typical imaging features associated with gas-forming infections of the gallbladder, stomach, pancreas, and genitourinary system will help make early diagnosis and successful treatment possible. In addition, such knowledge will aid in further diagnostic work-up, surveillance of potential complications, and evaluation of therapeutic response. Copyright RSNA, 2002
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                Author and article information

                Journal
                Indian J Endocrinol Metab
                Indian J Endocrinol Metab
                IJEM
                Indian Journal of Endocrinology and Metabolism
                Medknow Publications & Media Pvt Ltd (India )
                2230-8210
                2230-9500
                May-Jun 2013
                : 17
                : 3
                : 442-445
                Affiliations
                Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
                Author notes
                Corresponding Author: Dr. Mahdi Kamoun, Department of Endocrinology, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia. E-mail: mahdi_kamoun@ 123456yahoo.fr
                Article
                IJEM-17-442
                10.4103/2230-8210.111637
                3712373
                23869299
                Copyright: © Indian Journal of Endocrinology and Metabolism

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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