First AD

Second AD

A 50-year-old diabetic patient presented with fever, dysuria and abdominal pain.


Axial and coronal CT of the abdomen shows gross enlargement and destruction of left renal parenchyma with bubbly areas of gas collection within the parenchyma.

Emphysematous pyelonephritis is a life-threatening necrotizing infection characterized by gas formation within or surrounding the kidneys.

 Rapidly progressive with high morbidity and mortality.

 Poorly controlled diabetes and immunocompromised status are predisposing conditions.

Mottled gas within the renal fossa or crescentic collections of gas within the Gerota fascia

 Enlarged kidney with nondependent echoes in the renal parenchyma or collecting system

 Kidney may be completely obscured by large amount of perinehric gas

 The distal shadowing have “comet tail” reverberations and low-level echoes that are termed as “dirty shadowing.” Distinguishing them from calculi.

 However, US examination may be affected by the patient’s obesity or bowel meteorism. Additionally bowel gases and calculi are confounding factors. 

• Mottled areas of low attenuation extending radially along the pyramids with parenchymal enlargement and destruction.

• Fluid collections and gas-fluid levels

Type I: Streaky or mottled gas in interstitium of renal parenchyma radiating from medulla to cortex. No fluid collections.

Type 2: Bubbly and/or loculated intrarenal gas with renal and/or perirenal fluid collection.

• Type I is associated with worse prognosis.

Aggressive medical treatment along with percutaneous drainage and partial or complete nephrectomy.

1. Craig W, Wagner B, Travis M. Pyelonephritis: Radiologic-Pathologic Review. 

2. Woodward S, Elsayes K, Akhtar A. Imaging of Emphysematous Pyelonephritis: Self-Assessment Module. 

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50-year-old diabetic patient presented with fever, dysuria, and abdominal pain.

Image IQ: 50-year-old Diabetic with Fever, Dysuria, Abdominal Pain