Severe emphysematous pyelonephritis as a complication of klebsiella pneumonia and uncontrolled diabetes mellitus

A female in her 40s, with poorly controlled Type I diabetes mellitus, was brought to our tertiary hospital by ambulance after being found drowsy. Six days prior, she had self-discharged from the Intensive Care Unit whilst being treated for a Klebsiella pneumonia. At re-admission, she had an acute kidney injury with abdominal pain and clinical features of sepsis. Her presentation was attributed to ongoing Klebsiella pneumoniae infection; however, a chest radiograph showed marked improvement of pulmonary consolidations and an unusual subdiaphragmatic gas pattern. A CT scan demonstrated severe bilateral emphysematous pyelonephritis. The patient was unfit for bilateral nephrectomy and was medically managed in the Intensive Care Unit for 41 days, before transfer to a specialist renal unit for life-long haemodialysis. This case highlights the importance of considering emphysematous pyelonephritis in patients presenting with uncontrolled diabetes mellitus and acute kidney injury and/or infection, the role of imaging in its diagnosis, and the challenges of complex social circumstances in health management.