Emphysematous pyelonephritis with acute renal failure

A 56-year-old woman with obesity and poorly controlled diabetes mellitus presented with a two-day history of abdominal fullness and vomiting. No fever, flank pain or dysuria was present. On admission, her blood urea nitrogen concentration was 74 mg per deciliter and the serum creatinine concentration was 3.5 mg per deciliter. Laboratory data revealed an elevated white blood cell count (11-72 x 10(3)/ml), blood Sugar (826 mg/dl), pyuria (WBC 30-50/HPF) and negative urine ketone. A plain abdominal radiograph revealed right renal stones and localized air accumulation at the left upper abdominal area.