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Images in Neurology
November 2017

Infectious Pneumorrhachis Due to Emphysematous Pyelonephritis

Author Affiliations
  • 1Department of Pathology and Division of Infectious Diseases and Geographic Medicine, Stanford School of Medicine, Stanford, California
  • 2University of Colorado–Denver, Division of Stroke, Department of Neurology, Aurora (Vela-Duarte)
  • 3Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Neurol. 2017;74(11):1374-1375. doi:10.1001/jamaneurol.2017.2340

A man in his early 60s with diabetes presented critically ill, in septic shock, after a 3-day course of fever that was associated with lower abdominal pain and back pain. His examination was remarkable for hypotension, diaphoresis, a large ventral hernia defect, and bilateral costovertebral angle tenderness without peritonitis or neurologic abnormalities. A computed tomographic scan of the abdomen showed emphysematous changes within the parenchyma of both kidneys, the collecting systems and ureters extending distally toward the bladder, and intervertebral discs T11 and T12 (Figure 1). Multiple foci of gas were observed within the epidural space from T10 to L1 (Figure 2). The T12-L1 intervertebral disc space, vertebral body, and anterior soft tissue were dissected by gas (Figure 2). A diagnosis of emphysematous pyelonephritis with secondary pneumorrhachis was made. The patient required vasopressor support, broad-spectrum antibiotics, and insertion of percutaneous nephrostomy tubes. Blood and urine cultures grew pan-susceptible Escherichia coli, and his glycosylated hemoglobin level was 14.9%.

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