Emphysematous Pyelonephritis Presenting as Pneumaturia and the Use of Point-of-Care Ultrasound in the Emergency Department

Emphysematous pyelonephritis (EPN) is a rare form of pyelonephritis causing a severe infection of the renal system that includes gas in the renal parenchyma, collecting system and surrounding tissue often presenting with sepsis. We report the case of a 60-year-old male with poorly controlled insulin dependent diabetes mellitus who presented with abdominal pain, nausea, vomiting, and “peeing air.” CT scan revealed air extending from the left renal parenchyma, perinephric fat and into the bladder, consistent with emphysematous pyelonephritis. Bedside point-of-care ultrasound (POCUS) subsequently revealed dirty shadowing and reverberation artifacts in the left kidney and the bladder consistent with gas in the urinary collecting system. By understanding the identifying artifacts seen with EPN, reflective shadow and reverberation artifact, the emergency physician may be alerted to the diagnosis sooner. Often this illness presents similarly to simple, acute pyelonephritis or undifferentiated sepsis. Therefore, POCUS allows for real time consideration of this condition while in the emergency department and thus prompter time to treatment.