Emphysematous pyelonephritis in a renal transplant patient.

A 60-year-old woman, who had received a post-mortal donor renal transplant six weeks ago because of unknown end-stage renal disease, was re-admitted because of fever. Her post-transplant course had been complicated by steroid-induced diabetes mellitus and bladder retention for which she had learned self-catheterisation. Immunosuppressive therapy consisted of prednisolone, tacrolimus and mycophenolate-sodium. On admission, she complained of general malaise and fever for the last 24 hours. On physical examination, she was disoriented and hypotensive with a temperature of 38.4°C. The abdomen was distended and high pinched bowel sounds were heard. The renal transplant in the right iliac fossa was slightly tender on palpation. Laboratory investigation demonstrated a rise in plasma creatinine from 93 μmol/l to 539 μmol/l; C-reactive protein was 390 mg/l and leucocytes were 15.8 x 10/l. Urinary sediment showed >20 leucocytes/high power field. An abdominal X-ray was performed because concomitant ileus was suspected (figure 1).