Angiography in inflammatory space-occupying lesions of the kidney.

Abstract

Renal and perirenal abscesses are relatively uncommon conditions which usually present a difficult diagnostic problem. In the majority of the 210 cases reported to date, the correct diagnosis has not been considered preoperatively despite the detection of a renal mass by intravenous urography (3, 8). Urinalysis is often unrevealing, and there are few if any early localizing signs or symptoms. With the increasing utilization of arteriography in the evaluation of lesions of the kidney, abscess should now be included as a serious consideration among the differential possibilities. As there has been little written regarding the arteriographic findings in this condition (10), we have been prompted to present our experience with five patients seen at Montefiore Hospital between 1963 and 1965. Clinical Material The pertinent clinical, laboratory, and pathologic data are summarized in TABLE 1. A correct preoperative diagnosis was offered in CASES II and IV. In the remaining 3 cases, a diagnosis of renal inflammatory disease was suggested, but it was felt that necrotic renal carcinoma could not be definitely excluded. Discussion Renal abscess is usually of staphylococcal origin, the result of blood-stream invasion from a focus of infection elsewhere in the body. The primary lesion is commonly in either the skin or respiratory or urinary tract and is often completely healed by the time the renal abscess is clinically apparent. Numerous small septic emboli become lodged in the smaller arteries of the kidneys, multiply, and form many small abscesses which then coalesce. Less frequently, the renal infection is secondary to ascending suppurative pyelonephritis with lymphatic extension; the causative organism in such cases is usually of the coliform group. Once the abscess has formed, there are three major routes of spread: (a) extension to the renal capsule with perinephric extension; (b) perforation into the renal pelvis with drainage, and (c) progression to a chronic abscess (3). Renal inflammatory space-occupying lesions have a male sex predominance of approximately 2 to 1 and are usually unilateral, occurring more often on the right side. The average patient is approximately twenty-five years of age, although renal abscess has been reported from the age of twenty-eight weeks to the seventh decade. The classic clinical picture is that of sepsis: fever, chills, malaise, nausea, vomiting, and leukocytosis. Localizing symptoms such as flank pain, guarding, and tenderness are rare and, when present, occur late in the course of the disease. A history of recent skin infection is helpful, and occasionally a history of trauma may be obtained. Trauma would seem to make the kidney more susceptible to infection. Urinary symptoms are infrequent, and urinalysis is of little or no diagnostic aid. The correct preoperative diagnosis to date has been made in less than 20 per cent of the cases (3).