Aeromonas hydrophila-associated Emphysematous Pyelonephritis in a Failed Renal Allograft Causing Sepsis and Graft Nephrectomy

Emphysematous pyelonephritis (EPN) is a life-threatening necrotizing infection of the renal parenchyma characterized by gas formation. It is rare in renal allografts and usually caused by Enterobacterales. Aeromonas hydrophila is an uncommon etiological agent, particularly in transplant recipients. We report a 32-year-old male with end-stage kidney disease who underwent deceased donor renal transplantation and later developed graft failure following acute antibody-mediated and T-cell-mediated rejection. He presented with fever, right flank pain, and oliguria. Imaging revealed EPN of the transplanted kidney with absent graft vascularity and fistulous extension to the anterior abdominal wall. Blood culture and pus culture grew A. hydrophila . The patient developed sepsis with septic emboli, pulmonary thromboembolism, and disseminated intravascular coagulation. He was successfully managed with broad-spectrum antibiotics, incision and drainage, and maintenance hemodialysis. Graft nephrectomy was done in view of nonfunctioning graft. This case highlights A. hydrophila as a rare but aggressive pathogen causing EPN in a renal allograft. Early recognition, prompt imaging, microbiological diagnosis, and multidisciplinary management are critical to improving outcomes.