(1515) Venous Air Embolism due to Emphysematous Pyelitis

Introduction: Emphysematous pyelitis (EP) represents a gas-forming urinary tract infection (UTI) of the collecting system. Major risk factors include urinary tract obstruction, diabetes mellitus, and female sex. EP has been considered benign since it typically responds well to antibiotics and carries a favorable prognosis. Fewer than 20 case reports describe venous gas as a consequence of EP.

Description: An 86-year-old woman with a history of controlled atrial fibrillation and rheumatoid arthritis presented to the emergency department following multiple ground-level falls at home over several days, with concurrent acute dysuria, abdominal pain, emesis, dry cough, and confusion. Previously, she was in her usual state of health with no recent hospitalizations or procedures.

CT imaging showed multiple foci of gas in the bilateral jugular veins, chest wall venous collaterals, right atrium and ventricle, and main pulmonary artery. Abdominal imaging was not completed initially due to her hemodynamic instability.

Upon admission to the intensive care unit, she was placed in Trendelenburg position and given high-flow oxygen and empiric antibiotics. An internal jugular central venous catheter was placed as her vasopressor needs escalated, transducing a central venous pressure (CVP) of 18mmHg.

Her shock improved with supportive care over 24 hours, associated with normalization of her CVP. Repeat CT imaging demonstrated an obstructive stone in the right renal pelvis associated with free air in the collecting system, as well as interval resolution of gas in the systemic circulation.

She underwent emergent cystoscopy and ureteral stent placement under general anesthesia. Blood cultures grew pan-susceptible E. coli. Her shock resolved, and she was extubated the next day. She was discharged to complete her antibiotic course and followed up as an outpatient for definitive management of her renal pelvic stone.

Discussion: Venous gas due to emphysematous UTI is extremely rare and previously considered benign. This is the first reported case of emphysematous UTI causing hemodynamically significant venous air embolism. Awareness of this catastrophic complication can shorten time to diagnosis and appropriate therapy, which may reduce the risk of neurologic and other complications of air embolism and shock.