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A patient with vague and atypical symptoms is described in whom the radionuclide dynamic and static imaging studies proved to be more useful than a preceding excretory urogram for the diagnosis of unilateral pyelonephritis.
Emphysematous pyelonephritis is a rare complication of urinary tract infection and generally occurs in patients with diabetes mellitus or urinary tract obstruction. We recently treated an 81-year-old diabetic woman with Klebsiella pneumoniae urinary tract infection and septicemia whose abdominal roentgenogram demonstrated a striking left pneumonephrogram as well as intraureteral and perirenal gas. The patient died despite intensive therapeutic efforts. Unfortunately, the prognosis for this severe necrotizing infection process remains unfavorable.
Three cases of emphysematous pyelonephritis are presented. All 3 patients were diabetics, they all had Escherichia coli and there was evidence of ureteral obstruction in 1 case only. All 3 patients underwent nephrectomy and survived. Initial evaluation should be performed to rule out ureteral obstruction. Treatment should consist of a brief trial of high dose antibiotic therapy with serious consideration of nephrectomy in the face of persistent symptoms or gas. Incision and drainage are reserved for poor surgical risk patients. All patients should remain on antibacterial therapy and have frequent followup examinations.
We report a rare case of a 24-year-old woman who presented during her second trimester of pregnancy with a presumptive diagnosis of right-sided xanthogranulomatous pyelonephritis (XGP). Despite attempted conservative management, the patient ultimately required a right nephrectomy without complications to either the patient or fetus. Pathology confirmed the diagnosis of XGP of the right kidney. Herein, we present a case report and a review of the literature concerning XGP and pregnancy.
OBJECTIVES: Xanthogranulomatous pyelonephritis (XGP) is an atypical form of chronic renal infection. The treatment of choice is open nephrectomy, which is challenging, given the extent of the disease and the not uncommon involvement of the renal hilum and contiguous structures. We compared our experience with laparoscopic nephrectomy for histologically confirmed XGP with the open approach. METHODS: Review of all nephrectomy specimens at Washington University School of Medicine from July 1990 to March 1998 disclosed 9 patients with a pathologic diagnosis of unilateral XGP, of whom 5 patients underwent laparoscopic nephrectomy and 4 underwent open nephrectomy. XGP was suspected preoperatively in 56% of the patients. RESULTS: For the laparoscopic group, the average operating room time was 360 minutes, average blood loss was 260 mL, and complications occurred in 60% of patients (1 conversion to open, 1 ileus, 1 pulmonary embolus). For the open group, the average operating room time was 154 minutes, average blood loss was 438 mL, and there were no complications. Both groups were similar regarding time to oral intake, analgesia requirement, hospital stay, and time to complete recovery. CONCLUSIONS: Our early experience demonstrates that the benefits of laparoscopic nephrectomy, at present, do not extend to patients with XGP. Conventional open surgery is quicker, associated with fewer complications, and results in a similar use of analgesics, hospital stay, and recovery time.
OBJECTIVES: To differentiate acute pyelonephritis (APN) from fever due to other sources in patients with spinal cord injury by using technetium-99m dimercaptosuccinic acid (DMSA) renal cortex scintigraphy (DMSA scan). METHODS: A total of 24 patients with spinal cord injury were admitted with fever. DMSA scans were performed on all patients. The final determination of the cause of the fever was based on the medical history, physical examination, laboratory evaluation, and imaging studies. RESULTS: DMSA scan accurately diagnosed APN in 12 patients with inflammation on the DMSA scan. In 5 patients with scarred lesions on the DMSA scans and in 7 patients with negative DMSA scan, the fever was attributed to other causes. The sensitivity and specificity of the DMSA scan for detecting APN were both 100%. CONCLUSIONS: The DMSA scan is a valuable adjunct in the evaluation of fever in patients with SCI.
OBJECTIVES: To review 12 patients with a clinicopathogenic diagnosis of xanthogranulomatous pyelonephritis (XGP) and to determine if a computed tomography (CT) scan is the imaging procedure of choice for diagnosis. METHODS: A retrospective review, over the last 12 years, of patients with XGP at our institution. RESULTS: Nine of 10 patients (90%) who were evaluated by CT scan had the correct diagnosis made prior to nephrectomy. The most common presenting symptoms and signs were flank pain (64%), leukocytosis (73%), and anemia (82%). Seventy-five percent of the patients had a ureteropelvic junction stone or a staghorn stone in the affected kidney at the time of clinical presentation. Proteus was the most common organism cultured. CONCLUSIONS: After reviewing the clinical features of these 12 patients, we recommended CT scan to evaluate the patient in whom clinical suspicion of XGP is entertained. CT has proven to be the most accurate imaging study to evaluate this disease.
Strains of Escherichia coli isolated from patients with suspected pyelonephritis had a strong predilection for growth in kidney tissue. Viable bacterial counts in experimentally infected mice showed that after 96 hours approximately 98% of the total-body count was found in the kidney. Strains of E. coli isolated from cases of gastroenteritis in man and animals had little or no tendency to grow in the kidney. Treatment of male and female mice with oestrogen significantly enhanced the growth of "pyelonephritic" strains in the kidney, but had no effect of any kind on the growth of "gastroenteritis" strains. These preliminary results suggest that oestrogen may predispose to the development of kidney infection in the female and that there is an important link with the virulence of the E. coli concerned. Only those strains that have a natural predilection for growth in the kidney are likely to be influenced by oestrogen.
A survey was undertaken of the clinical, radiological, ultrasonic, and pathological features of 80 patients with xanthogranulomatous pyelonephritis (XPN). The condition is a progressive granulomatous reaction to chronic renal inflammation which is often suppurative and usually caused by calculous urinary tract obstruction. The characteristic pathological features are large numbers of foam cells containing lipid, and the presence of inflammatory destruction of neighbouring renal tissue. XPN, which is commoner than generally recognised, may often be diagnosed preoperatively--the patient is usually a middle-aged female who presents with severe toxaemia, tender loin mass, and mild lower urinary tract symptoms. The diagnosis is confirmed by radiology and ultrasonography. Nephrectomy is curative.
The role of free radical scavengers in preventing the tissue injury using a non obstructive, ascending mouse model for chronic pyelonephritis was assessed. The parameters taken into consideration are Luminol Dependent Chemiluminescence (LDCL), histopathology and some biochemical investigations. We have observed that both catalase and Dimethyl-Sulfoxide (DMSO, free radical scavengers) were able to prevent the free radical mediated tissue injury and ultimate renal scarring, irrespective of the bacterial strain studied.
The contribution of iron towards the free radical generation leading to renal tissue damage was assessed using a non-obstructive ascending mouse model for chronic pyelonephritis. The parameters studied include luminol dependent chemiluminescence (LDCL), histopathology and some biochemical investigations. We found that iron enhanced the renal tissue damage and led to renal scarring, and end point in chronic renal inflammation, irrespective of the bacterial strain studied. In addition a role of iron chelation therapy as a treatment for chronic renal inflammation is also suggested.
Cell surface hydrophobic properties and expression of P-fimbriae were examined in 130 strains of Escherichia coli derived from women (n = 66) and children (n = 64) with acute non-obstructive pyelonephritis and in 170 faecal strains of E. coli from healthy adults (n = 103) and children (n = 67) by use of the salt aggregation test and the P-fimbriae-specific particle agglutination test. The strains of E. coli isolated were aggregated in salt solutions of varying molarity (0.001-1.6 M final concentration). Patients with predisposing medical or urological conditions in the urinary tract were excluded. Pyelonephritic strains of E. coli from the women and children had a higher degree of cell surface hydrophobicity (80 and 98% respectively) than faecal strains from healthy adults and children (57 and 82% respectively, P less than 0.01 and P less than 0.01). Both pyelonephritic and faecal strains of E. coli from the children were more often salt aggregation positive (hydrophobic) than faecal strains of E. coli from healthy adults (P less than 0.01 and P less than 0.001, respectively). Pyelonephritic strains of E. coli from women and children were more often P-fimbriated (79 and 84% respectively) than faecal control strains from women and children (15 and 33%, P less than 0.001 and P less than 0.001, respectively) but there was no significant correlation between expression of P-fimbriae and cell surface hydrophobicity.
It has been shown that the mere presence of gram-negative bacteria within the kidney parenchyma does not lead to kidney damage. Various accessory manipulations modifying the resistance of the urinary tract should be used to induce kidney lesions. We present the results of our experiments with sterile bacterial filtrate applied accordingly to the technique of Shwartzman phenomenon. This way we produced experimental acute pyelonephritis in rats by an ascending route of infection. A significant pathogenic activity of sterile bacterial filtrate in comparison with saline was shown producing clinically relevant infections of the urinary tract in rats infected by concentrations of E. coli suspensions of 10(4) and 10(5) cfu/ml.
Henoch-Schönlein purpura is a systemic vasculitis of unknown cause. It is frequently triggered by a streptococcal upper respiratory tract infection. Other bacteria have been implicated as triggering agents. We report a recurring case of Henoch-Schönlein purpura in a patient with Pseudomonas pyelonephritis. The Henoch-Schönlein purpura remitted only when the infection was eradicated. Pseudomonas infection should be added to the list of bacteria that can trigger Henoch-Schönlein purpura.
Emphysematous pyelonephritis is a necrotizing renal parenquima infection, which is diabetes mellitus related in almost all cases. This is life threatening and has a high mortality rates despite aggressive management. The most important thing in management is a high diagnostic suspicious and also a rapid treatment, which means nephrectomy. We expose a case giving especial importance to clinical and image diagnose as treatment and evolution. We also make a literature review trying to understand this entity and find pathways for its therapeutic management.
In chronic experimental and human pyelonephritis (PN) renal enzyme and phosphatide analyses as well as quantitative histological examinations were performed simultaneously. The results reported in this study only refer to fumarase (FUM) activities. Glomerular FUM-activities initially increased steeply up to 31 days, thereafter the values decreased, but being still elevated till 212 days. Only in the 261-days series the FUM-activities were absolutely decreased. In the cortical tubules of the rabbit kidneys the enzyme activities also steeply increased until 64 days, in the 100-days-series they were already depressed. After 212 and 261 days the tubular FUM-activities were extremely depressed. In the medulla the FUM-activities similarly showed steeply increasing values till 31 days. Thereafter a decrease was stated in the 64-days-series persisting up to 100 days. Finally, the values were pathologically depressed in the 212- and 261-days-series. In the "spontaneously healed up" tissue the glomerular FUM was slightly increased, the cortico-tubular one was more increased whereas the medullar activities were decreased. The human samples of pyelonephritic nephrocirrhosis showed about half than the normal FUM-activities in the glomerula. In the cortical tubules they were still more depressed. Also in the medulla the values were decreased. The significance calculations (universally applied t-test) showed an overwhelming majority of values with significance (p less than 0.001). The measured enzyme activities well correlate with the results of quantitative histological examinations.
In 139 adult male rabbits unilateral pyelonephritis (PN) was induced. In a broad spectrum of enzymes and phospholipids also the content of phosphatidylcholine (PC) was determined. Only these latter values are reported here. PC showed markedly increased levels up to the 20-d-, and to the 31-d-series in the cortex. After 64 and 100 d of experimental PN the content of PC was less than the half of the normal values, and after 261 d of disease, it was only about 1/16 of the normal value (= 22.58 +/- 1.55 micrograms P/g wet weight). In the medulla the PC increased only till the 20-d-series, but showed a marked decrease in the 31-d-series already, which is in contrast to the corresponding cortical situation. Thereafter the medullary PC decreased successively, so that only about 5 per cent of the normal value were found in the contracted kidneys of the 261-d-series (n = 13.58 +/- 1.24 microgramsP/g wet weight). The increased PC-concentrations should be due mainly to the increased cell contents, the following reductions being due to the lower cell contents of this interstitium. Other factors (induced synthesis and/or reduced decomposition) may be responsible to a lesser degree of probability. The strongly decreased PC concentrations in the chronic and late-chronic series are caused by the low cell-contents, increasing vascular changes, the augmented connective tissue, and the general epithelial damage of the remaining nephrons.
Emphysematous pyelonephritis is a rare, life-threatening complication of upper urinary tract infections, characterized by the presence of gas in renal parenchyma and perirenal space. It occurs in 90% of cases in diabetic patients and E coli is the most common causative germ. The pathogenesis probably involves several factors including enhanced proliferation of microorganisms due to altered immune defences, mixed acid fermentation of glucose leading to gas production, and decreased elimination of the gas because of impaired tissue perfusion. Diagnosis is often delayed because the symptoms may be non-specific, as illustrated by the two cases we report herein. In patients with diabetes and febrile urinary tract infection, obstruction of the urinary tract should first be eliminated by echography. Then, if the infection does not rapidly respond to antimicrobial therapy, a scan should be performed. Aggressive management including correction of hemodynamics, parenteral antimicrobial therapy, and diabetes control with insulin therapy is mandatory, but a surgical procedure (nephrectomy or drainage) is almost always required.