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Previous Volume 356:526-527 February 1, 2007 Number 5 Next

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To the Editor: The medical mystery in the December 7, 2006, issue¹ involved a 50-year-old woman who presented to the emergency department with obtundation and hypotension. An abdominal radiograph showed gas throughout the right kidney (Figure 1A). Computed tomography (CT) of the abdomen revealed extensive destruction of the right renal parenchyma with associated gas, as well as gas in the retroperitoneal tissues (Figure 1B). The patient's serum glucose level at presentation was 607 mg per deciliter (33.7 mmol per liter), and her glycated hemoglobin value was 12.2%. She did not have diabetic ketoacidosis. A diagnosis of emphysematous pyelonephritis in the setting of diabetes mellitus was made. The patient underwent urgent right nephrectomy, and Escherichia coli was cultured from the surgical site and from the blood. She had an uneventful recovery, with normalization of her renal function. Her newly diagnosed diabetes is well controlled through insulin therapy, and she is doing well.

View larger version (83K): [in this window] [in a new window]   Figure 1. Radiograph (Panel A) and CT Scan (Panel B) of the Patient's Abdomen.

 

Masahiko Kurabayashi, M.D., Ph.D.
Kumiko Tajima, M.D., Ph.D.
Gunma University Graduate School of Medicine
Gunma 371-8511, Japan
mkuraba{at}med.gunma-u.ac.jp

Editor's note: We received 1162 responses to this medical mystery — 55% from physicians in practice, 19% from physicians in training, 13% from medical students, and 13% from other readers. Responses were received from 82 countries. Many of the responses reflect a team effort — such as the results of a discussion of the case during a teaching conference.

Forty percent of the respondents correctly identified gas associated with the right kidney or emphysematous pyelonephritis. Eleven percent suggested a gallbladder disorder such as emphysematous cholecystitis, 12% suggested other infections (e.g., hydatid cyst or hepatic abscess), another 12% suggested cancer (e.g., renal, adrenal, or hepatic), and 19% suggested a variety of diagnoses, including pneumatosis coli, renal-vein thrombosis, intussusception, toxic megacolon, volvulus, pancreatic cyst, or a fecolith. The remaining 6% of respondents suggested a bezoar or an intraabdominal pregnancy, including the possibility of a lithopedion.

References

1. Tajima K, Kurabayashi M. Medical mystery -- abnormal abdominal radiograph. N Engl J Med 2006;355:2467-2467. [Free Full Text]

PDF PDA Full Text Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear Related Article by Tajima, K. PubMed Citation