**8. Complications of urinary tract infection in diabetics**

Emphysematous pyelonephritis (EPN) is a severe and necrotizing form of multifocal bacterial nephritis along with gas formation within parenchyma of the kidney. So far, more than 200 cases have been reported in literature. Underlying poorly controlled diabetes mellitus is present in up to 90% of affected patients [28].

The commonest offending organisms are Klebsiella and *Escherichia coli* followed by Proteus. The clinical manifestations are nonspecific and not different from the classic triad of upper UTI (i.e., fever, flank pain and pyuria); due to this, the diagnosis of EPN is often delayed. Disseminated intravascular coagulopathy, acute respiratory distress syndrome, disturbance of consciousness, acute renal failure, and shock can reveal some severe forms. Diabetic ketoacidosis is a very uncommon presentation, and only few cases have been reported so far.

EPN needs a radiological diagnosis. Conventional radiography may indicate gas bubbles overlying the renal fossa. Ultrasonography (US) characteristically shows an enlarged kidney that contains high amplitude echoes within the renal parenchyma. Computed tomography (CT) is the imaging procedure of choice, which confirms the presence and extent of parenchymal gas.
