Epinephrine-enhanced arteriography in renal and perirenal abscess. A differential diagnostic problem.

Abstract

Since the work of Abrams in 1964 (1), it has been believed that selective arteriography following epinephrine infusion would distinguish renal tumor vascularity by a failure of vasoconstriction. The purpose of this report is to present a case of a renal and perirenal abscess in which the vascular response to epinephrine mimicked that of a renal tumor and led to an incorrect diagnosis. Despite a single previous reported case (6) there still appears to be a misconception among radiologists (7) that the epinephrine response is specific. A 76-year-old white male was admitted to the Booth Memorial Hospital with a complaint of fever and left testicular swelling and tenderness of three weeks duration with no response to antibiotics. Urinalysis showed pus cells. The patient had undergone surgery for a renal stone twelve years earlier, and a prostatectomy had been performed fourteen years ago. Radiological Work-up: The plain film of the abdomen showed a calcification in the left renal area. The excretory urogram demonstrated a large mass in the lower pole of the left kidney with slight distortion of the calyces, as well as scalloping of the proximal ureter resembling ureteritis cystica (Fig. 1). The calcification was seen to be a lower-pole renal calculus. A nephrotomogram confirmed the presence of the mass and showed an indistinct margin between it and the kidney. A retrograde pyelo-gram (Fig. 2) verified the ureteritis cystica but added little other information. Selective left renal arteriography (Figs. 3, A and B, and 4, A) again showed a poorly defined margin between the lesion and the normal renal parenchyma. The mass also exhibited abnormal neovascularity and appeared to be fed at least partly by a capsular vessel arising close to the origin of the left renal artery. Selective arteriography, repeated twenty seconds after the injection of 20 micrograms of epinephrine through the catheter (Figs. 3,C and D; 4,B), demonstrated marked constriction of the intrarenal vessels as well as of the capsular vessel. The abnormal vessels in the mass failed to contract, however, and therefore received increased flow of contrast material, which enhanced their visualization (Fig. 4). A diagnosis of hypernephroma was made on this basis. At operation, a large hemorrhagic mass intimately adherent to the renal surface and measuring 9 cm in length and 2 cm in thickness was removed with the kidney. Pathological examination disclosed a large inflammatory mass with a large amount of granulation tissue and central necrosis involving a portion of the underlying renal parenchyma. Bacterial culture revealed E. coli. The lower pole of the kidney also contained a calculus. The final diagnosis was perirenal and renal abscess and nephrolithiasis. Discussion