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Twenty-eight cases of xanthogranulomatous pyelonephritis were studied in retrospect and difficulties in diagnosis and treatment are described. Awareness of the entity is the most effective safeguard against over-aggressive resection for this benign condition.
Eleven children with xanthogranulomatous pyelonephritis are reported. The left side was affected in all patients. It is suggested that the diagnosis can be made pre-operatively. The condition is characterised by the fact that it is always unilateral and that renal calculi are found in a kidney with gross impairment of function; associated anaemia, leucocytosis and raised ESR are also present. The cause is unclear, but an obstructive element with infection is usually found.
Fistula or deep sinus formation as a complication of xanthogranulomatous pyelonephritis (XPN) has not been described previously in the British literature. We present the clinicopathological features of one case of a nephrodiaphragmatic sinus complicating XPN, and three cases of nephrocolic fistula, including the first recorded case of fistula in childhood XPN. The detailed clinical, radiological and pathological features of XPN and its complications are reviewed. Total nephrectomy, together with primary excision of sinuses or fistulae, is the treatment of choice.
The computed tomographic findings in nine female patients with acute pyelonephritis were reviewed. The major impact of CT was the demonstration of renal enlargement, abnormal contour, perirenal inflammatory extension and, on contrast-enhanced scans, abnormal nephrograms and impaired renal function. It was concluded that CT can provide specific information about the nature and extent of the inflammatory process, thus complementing intravenous urography so that appropriate therapy may be selected. Follow-up studies can be helpful in monitoring the progress of a patient.
Sixteen patients with xanthogranulomatous pyelonephritis (XGP) are reported. The preoperative diagnosis of XGP may be difficult because of its clinical and radiological similarities to various other renal lesions, but in four patients XGP was suspected pre-operatively. Nephrectomy is necessary in most patients, although medical treatment may help a few.
A series of 14 patients with acute pyelonephritis was evaluated for the formation of renal scarring by serial computed tomography (CT) and intravenous urography. Although the urography results were normal, CT showed renal parenchymal atrophy (cortical scarring) in 6 patients. Cortical scarring was observed to occur after 61 to 187 days, and it was slower to develop in the patients with recurrent fever lasting for 2 weeks or more in total than in those with fever for less than 2 weeks. Scarring was significantly more frequent in patients with severe renal involvement than in those with mild involvement, and scars developed at the sites of the most extensive lesions seen on the initial CT scans. Cortical scars were detected in 6 of the 7 patients in whom the lesions occupied 30% or more of the renal parenchyma. We conclude that the extent of the initial renal parenchymal involvement was the most important determinant of eventual scar formation.
Four cases of emphysematous pyelonephritis are reported and the pathogenesis, surgical implications and preferred mode of management are discussed. We have not found percutaneous drainage to be useful, but feel there is an important place for surgical drainage alone because of the potential for renal recovery and the risks of emergency nephrectomy.
OBJECTIVE: To diagnose xanthogranulomatous pyelonephritis (XGP) in childhood pre-operatively. PATIENTS AND METHODS: Eleven cases of XGP presenting to Birmingham Children's Hospital over a 10-year-period are reported. Nine (82%) were diagnosed preoperatively on the clinical and radiological findings. RESULTS: The characteristic clinical findings were urinary tract infection (9 cases), palpable renal mass (8 cases) and anaemia (8 cases). The most common radiological findings were enlarged kidney (9 cases), renal calculi (7 cases) and non-functioning kidney (6 cases). Renal ultrasound typically demonstrated a central echoic area (6 cases) and multiple hypoechoic areas in the parenchyma (7 cases). A computed tomography (CT) scan was performed in three cases. This showed characteristic multiple, low attenuation, unenhanced areas within the parenchyma with extension of the inflammatory process into peri-nephric fat (two cases). Ten cases (91%) were of the diffuse type. There was extension into the peri-nephric fat in eight cases (73%). Three cases (27%) were associated with congenital urological abnormalities. Nephrectomy was performed in 10 cases and a partial nephrectomy in one. CONCLUSION: XGP is uncommon in childhood but should always be considered in the differential diagnosis of renal masses, especially in the presence of anaemia. Nephrectomy usually results in a permanent cure.
OBJECTIVE: To determine the clinico-pathological profile of patients with emphysematous pyelonephritis (EPN). PATIENTS AND METHODS: The records of 22 diabetic patients who presented with EPN were reviewed. RESULTS: EPN occurred predominantly in female diabetic patients without evidence of ureteric obstruction. The ages of the patients and the duration of the diabetes were variable. EPN occurred in insulin-dependent as well as non-insulin-dependent patients. The patients presented following a prodromal illness of urinary sepsis, with an acute severe illness with symptoms and signs on the affected side. Dehydration and ketoacidosis were common. The diagnosis was made by recognizing gas in the kidney on an X-ray or ultrasound. Eighteen patients were subjected to emergency nephrectomy. CONCLUSIONS: EPN is an uncommon, life-threatening condition characterized by the production of intraparenchymal gas. We believe that vigorous resuscitation and emergency nephrectomy is the treatment of choice.
The uptake of D-glucose, L-aspartate, L-lysine and L-proline was investigated in renal brush border membrane (BBM) vesicles prepared from control, infected or passively-immunized-infected rats. Except L-aspartate, a progressive decrease in the uptake of these nutrients in both infected and immunized-infected groups during the course of infection was observed, but the changes were less apparent in immunized-infected rats than in non-immunized ones. The uptake of L-aspartate was increased in vesicles from early stages of infection but decreased in those from later stages. Also in L-aspartate uptake, the changes were smaller in immunized animals. The uptake of nutrients was detectable earlier than were histopathological alterations of both kidneys. The observations demonstrated that uptake of D-glucose and amino acids in the kidneys is disturbed prior to appearance of histopathological lesions and thus can be used for early detection of the disease. The data also demonstrate that antipili antibodies afford partial protection against ascending pyelonephritis.
We report on a 6-year-old boy with Xanthogranulomatous pyelonephritis. This unusual type of renal inflammation has a typical clinical picture that is important to bear in mind. The affected child is often seriously ill with a palpable flank mass leading to initial suspicion of malignancy. Modern imaging procedures help in obtaining a pre-operative diagnosis.
During 9 attacks of M. hominis pyelonephritis in 8 patients, the presence of IgA, IgG and IgM antibodies in urine and serum was studied by an indirect immunofluorescence technique. Antibodies were present in the urine for a period of 12 days. One to 4 days after the onset of the attack, IgA was in all cases demonstrable in urine, followed later by IgG. IgM was present in the urine of one patient only during the first 4 days of illness. In serum, IgG appeared as early as 1-4 days after the attack, followed later by IgA and IgM, IgA disappearing after one to two weeks.
We investigated the prophylactic and therapeutic effect of human granulocyte-colony stimulating factor (G-CSF) on mice with ascending pyelonephritis induced by Pseudomonas aeruginosa (G-group). This experimental model was established by a two course administration of cyclophosphamide, so that it kept the mice in a neutropenic status (around 2000 white blood cells/mm3) from the time of infection to the time of sacrifice. The cyclophosphamide-treated group increased their susceptibility more than the control group. In the cyclophosphamide-treated group, the prophylactic administration of G-CSF (2 micrograms/day/mouse) yielded a lower incidence of infection and of infection-induced mortality than that of saline alone. However, the therapeutic administration of G-CSF did not produce significant decreases of these rates, suggesting that this type of administration had no effect on infection. At the time of sacrifice, the prophylactic administration of G-CSF increased the number of neutrophils, while at the time of induced infection, no increase of neutrophils was found. G-CSF therapeutic administration was not able to increase neutrophils during the experiment. An investigation of the bacterial capacity of peritoneal exudate neutrophils revealed that G-CSF prophylactic administration accelerated its capacity, although cyclophosphamide alone did not. These results suggest that G-CSF has a prophylactic effect on bacterial infection in neutropenic mice, and that this effect, in part, depends upon both the increase of neutrophils and the acceleration of bactericidal capacity produced by G-CSF.
The compromised host has recently increased because of the improvement of medical diagnosis and technology. Infection in the compromised host is somewhat different from that in common patients, since this infection is caused by impairment of the host defense mechanism. And the compromised host easily suffers from opportunistic infections. This situation prompted us to study the effect of biological response modifiers (BRMs), which activate the host defense mechanism against infections in the compromised host. We used streptozotocin (STZ)-induced diabetic mice, as experimental models of the compromised host. First, we investigated the bactericidal capacity of the perineal exudating neutrophils in diabetic mice, as one of the host defense mechanism. Second, we also studied the effect of Granulocyte-Colony Stimulating Factor (G-CSF) on diabetic mice with ascending pyelonephritis by P. aeruginosa. At 1 and 2 weeks after inducing the diabetic state, no difference was found in the bactericidal capacity of the perineal exudating neutrophils between normal mice and diabetic mice. At 3 weeks, however, this bactericidal capacity was markedly suppressed in these mice. This result suggested that a depression of host defense mechanisms in diabetics was caused by, in part, a suppression of bactericidal capacity of neutrophils. When G-CSF (2 micrograms/mouse) was injected subcutaneously once a day into diabetic mice, the suppression of the bactericidal capacity of neutrophils significantly recovered. We thus studied the effect of G-CSF on diabetic mice against infection. Diabetic mice increased their susceptibility to bacterial infection more than normal mice. In diabetic mice, administration of G-CSF (2 micrograms/mouse) yielded a lower incidence of infection and infection-induced mortality than those of controls. These data show that G-CSF may be of great value for prevention and treatment of opportunistic infections in the compromised host, especially in patients whose bactericidal capacity of neutrophils is depressed, as in diabetics.
We investigated the prophylactic effect of Ubenimex on mice with ascending pyelonephritis induced by Pseudomonas aeruginosa (G-group). This experimental model was established by a two course administration of cyclophosphamide, so that it kept the mice in a neutropenic status (around 2000 white blood cells/mm3) from the time of infection to the time of sacrifice. The cyclophosphamide-treated group increased their susceptibility more than the control group. In the cyclophosphamide-treated group, the prophylactic administration of Ubenimex (100 micrograms/day/mouse) did not produce significant decreases of infection-induced mortality rate, but yielded a lower incidence of infection than of saline alone. Administration of Ubenimex was not able to increase the number of neutrophils during the experiment. An investigation of the bactericidal capacity of peritoneal exudating neutrophils revealed that Ubenimex prophylactic administration accelerated its capacity, although cyclophosphamide alone did not. These results suggest that Ubenimex has a prophylactic effect on bacterial infection in neutropenic mice, and that this effect, in part, depends upon the acceleration of bactericidal capacity of neutrophils produced by Ubenimex.
We reported the prophylactic and therapeutic effect of human granulocyte-colony stimulating factor (G-CSF) on mice with ascending pyelonephritis induced by Pseudomonas aeruginosa (G-group). In the cyclophosphamide-treated neutropenic mice, the prophylactic administration of G-CSF (2 micrograms/day/mouse) yielded a lower incidence of infection than that of saline alone. However, the therapeutic administration of G-CSF (2 micrograms/day/mouse) did not produce decreases of the rate, suggesting that this type of administration had no effect on infection. Thus, we investigated the effect of the combination therapy of G-CSF and Amikacin. In neutropenic mice, the therapeutic administration of G-CSF alone and Amikacin (20 mg/kg) alone did not produce decreases of incidence of infection. But, combination administration of these yielded a lower incidence of infection. These results suggest that synergy of bactericidal effects of neutrophils accelerated by G-CSF with Amikacin, and a combination of these have a therapeutic effect on bacterial infection in neutropenic mice.
The activities of ampicillin, rifampin, streptomycin, and their combinations were evaluated in vitro against Streptococcus faecalis strain GK and in vivo in rats with an established pyelonephritis resulting from challenge with this same enterococcus. In vitro synergy was demonstrated between all combinations. Comparison of the log colony-forming units of S. faecalis recovered per gram of kidney tissue showed that all treated groups had significant lower numbers than controls (P less than 0.001). Ampicillin plus streptomycin or ampicillin alone was superior to rifampin alone or rifampin plus streptomycin at each interval (P less than 0.001). There was no significant difference between ampicillin and rifampin plus ampicillin. The disparity between in vitro and in vivo results again raises some doubts as to the relevance of in vitro observations to clinical outcome.
Itraconazole and fluconazole, two new triazoles, were examined for their antifungal activity in rabbits. Fluconazole easily crossed the blood-cerebrospinal fluid barrier, and active drug was eliminated in high concentrations in the urine. On the other hand, itraconazole did not cross the blood-cerebrospinal fluid barrier in measurable amounts, and urine concentrations were variable. Despite differences in pharmacokinetics at the site of infection, both agents were equally effective in treating cryptococcal meningitis and candida pyelonephritis in animals. By using a ketoconazole-resistant strain of Candida albicans, we showed that there was cross-resistance in vivo between these two new triazole compounds.