Lemierre’s syndrome variant with inferior vena cava and right common iliac vein thrombosis secondary to emphysematous pyelonephritis

Abstract

Abstract Background Emphysematous pyelonephritis (EPN) is a potentially life-threatening disease with Escherichia coli (E. coli) being the most common aetiology. Infection can involve the renal parenchyma, collecting system and perinephric tissues, and is commonly encountered in patients with uncontrolled diabetes mellitus. EPN complicated by suppurative thrombophlebitis of the inferior vena cava is a rare occurrence. Our case had thrombosis of the right common iliac vein as well, which is first of its kind reported with EPN. Case presentation We describe a case of a 59-year-old male patient, with uncontrolled diabetes mellitus, who presented to the emergency department with a history of high-grade fever and left loin pain. Clinico-laboratory findings were diagnostic for diabetes mellitus, complicated by upper urinary tract infection with sepsis. A preliminary ultrasound of the abdomen was indicative of left hydronephrosis with features of emphysematous pyelonephritis. Abdominal computed tomography (CT) was done to ascertain the cause of hydronephrosis. Left ureteric calculus complicated by emphysematous pyelonephritis (type 3a) with intraluminal air in the left renal vein and inferior vena cava (IVC). Culture grew E. coli. Patient was started on insulin and intravenous (IV) antibiotics, and bilateral DJ stenting was done. Patient was symptomatically better and was discharged. A month later, he was readmitted with relapse of symptoms; repeat CT showed left perinephric abscess, with left renal vein, inferior vena cava and right common iliac vein thrombosis. Repeat culture grew E. coli, stent was replaced, and subsequently he underwent ultrasound-guided aspiration for left perinephric abscess. Haemodialysis along with IV antibiotics and anticoagulant therapy was started. Conclusion Suppurative thrombophlebitis of the inferior vena cava in association with EPN is rare; however, the same is associated with higher morbidity and mortality. Prompt diagnosis, drainage procedure, antibiotics coupled with anticoagulants are the mainstay of treatment for deep venous thrombophlebitis.

Keywords

• Emphysematous pyelonephritis
• IVC thrombosis
• Common iliac vein thrombosis
• Pneumo vena cava and diabetes mellitus