Medscape is available in 5 Language Editions – Choose your Edition here.


Emphysematous Pyelonephritis (EPN) Differential Diagnoses

  • Author: Sugandh Shetty, MD, FRCS; Chief Editor: Edward David Kim, MD, FACS  more...
Updated: Dec 30, 2015

Diagnostic Considerations

Another septic condition, xanthogranulomatous pyelonephritis, which is usually associated with stones in a nonfunctioning kidney with a severe gram-negative infection, is very similar in presentation to emphysematous pyelonephritis (EPN).

Xanthogranulomatous pyelonephritis may also produce gas in the renal parenchyma and perinephric space, but generally not to the degree observed with EPN. The treatment of xanthogranulomatous pyelonephritis is strictly surgical, requiring early nephrectomy because the kidney is already nonfunctional and is not worth saving. As previously mentioned, acute pyelonephritis also has a presentation similar to that of EPN.

Differential Diagnoses

Contributor Information and Disclosures

Sugandh Shetty, MD, FRCS Associate Professor of Urology, Oakland University William Beaumont School of Medicine; Attending Physician, Department of Urology, William Beaumont Hospital

Sugandh Shetty, MD, FRCS is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ajay K Singh, MB, MRCP, MBA Associate Professor of Medicine, Harvard Medical School; Director of Dialysis, Renal Division, Brigham and Women's Hospital; Director, Brigham/Falkner Dialysis Unit, Faulkner Hospital

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

  1. Kelly HA, MacCullum WG. Pneumaturia. JAMA. 1898. 31:375-81.

  2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27. 160(6):797-805. [Medline].

  3. Tang HJ, Li CM, Yen MY, et al. Clinical characteristics of emphysematous pyelonephritis. J Microbiol Immunol Infect. 2001 Jun. 34(2):125-30. [Medline].

  4. Wan YL, Lo SK, Bullard MJ, Chang PL, Lee TY. Predictors of outcome in emphysematous pyelonephritis. J Urol. 1998 Feb. 159(2):369-73. [Medline].

  5. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997 Mar. 49(3):343-6. [Medline].

  6. Pontin AR, Barnes RD, Joffe J, Kahn D. Emphysematous pyelonephritis in diabetic patients. Br J Urol. 1995 Jan. 75(1):71-4. [Medline].

  7. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol. 1997 May. 157(5):1569-73. [Medline].

  8. Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis. A new case and review of previous observations. Am J Med. 1968 Jan. 44(1):134-9. [Medline].

  9. Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol. 1991 Jul. 146(1):148-51. [Medline].

  10. Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol. 1990 May. 143(5):960-4. [Medline].

  11. Cheng YT, Wang HP, Hsieh HH. Emphysematous pyelonephritis in a renal allograft: successful treatment with percutaneous drainage and nephrostomy. Clin Transplant. 2001 Oct. 15(5):364-7. [Medline].

  12. Wang YC, Wang JM, Chow YC, Chiu AW, Yang S. Pneumomediastinum and subcutaneous emphysema as the manifestation of emphysematous pyelonephritis. Int J Urol. 2004 Oct. 11(10):909-11. [Medline].

  13. Tsu JH, Chan CK, Chu RW, Law IC, Kong CK, Liu PL, et al. Emphysematous pyelonephritis: an 8-year retrospective review across four acute hospitals. Asian J Surg. 2013 Jul. 36(3):121-5. [Medline].

  14. Fatima R, Jha R, Muthukrishnan J, Gude D, Nath V, Shekhar S, et al. Emphysematous pyelonephritis: A single center study. Indian J Nephrol. 2013 Mar. 23(2):119-24. [Medline]. [Full Text].

  15. Langston CS, Pfister RC. Renal emphysema. A case report and review of the literature. Am J Roentgenol Radium Ther Nucl Med. 1970 Dec. 110(4):778-86. [Medline].

  16. Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol. 1984 Feb. 131(2):203-8. [Medline].

  17. Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology. 1996 Feb. 198(2):433-8. [Medline].

  18. Uruc F, Yuksel OH, Sahin A, Urkmez A, Yildirim C, Verit A. Emphysematous pyelonephritis: Our experience in managing these cases. Can Urol Assoc J. 2015 Jul-Aug. 9 (7-8):E480-3. [Medline].

  19. Aboumarzouk OM, Hughes O, Narahari K, Coulthard R, Kynaston H, Chlosta P, et al. Emphysematous pyelonephritis: Time for a management plan with an evidence-based approach. Arab J Urol. 2014 Jun. 12 (2):106-15. [Medline].

  20. Nana GR, Brodie A, Akhter W, Karim O, Motiwala H. Nephroureterectomy for emphysematous pyelonephritis: An aggressive approach is sometimes necessary. A case report and literature review. Int J Surg Case Rep. 2015. 10:179-82. [Medline].

  21. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: outcome of conservative management. Urology. 2008 Jun. 71(6):1007-9. [Medline].

  22. Sharma PK, Sharma R, Vijay MK, Tiwari P, Goel A, Kundu AK. Emphysematous pyelonephritis: Our experience with conservative management in 14 cases. Urol Ann. 2013 Jul. 5(3):157-62. [Medline]. [Full Text].

  23. Gaither K, Ardite A, Mason TC. Pregnancy complicated by emphysematous pyonephrosis. J Natl Med Assoc. 2005 Oct. 97(10):1411-3. [Medline]. [Full Text].

Kidneys, ureter, and bladder imaging showing a streaky gas pattern over the entire right kidney in a patient with emphysematous pyelonephritis.
Emphysematous pyelonephritis. Kidneys, ureter, and bladder imaging showing gas over the region of the right kidney. White arrows outline the area. The faint outline of a staghorn calculus can be seen in the right kidney.
Emphysematous pyelonephritis. Renal sonogram showing hyperechoic shadows suggestive of gas along the lower pole of the kidney.
Emphysematous pyelonephritis. CT scan showing gas in the left kidney, with stones and xanthogranulomatous pyelonephritis.
CT scan showing right renal and perinephric gas in a patient with emphysematous pyelonephritis.
CT scan showing gas in both kidneys and the inferior vena cava in a patient with bilateral emphysematous pyelonephritis.
Algorithm for the management of emphysematous pyelonephritis.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.