Perinephric Abscess Research Articles

Unusual presentation of giant perinephric abscess with lower limb involvement

Perinephric abscess is a complication of urinary tract infection. It has the potential to extend beyond the Gerota’s fascia and cause serious illness. We report for the first time on an unusual presentation of a perinephric abscess crossing anatomical sections and extending through the inguinal canal to the ipsilateral lower limb. Treatment was immediate and involved multi-disciplinary operations.

Percutaneous nephroscopy combined with ultrasound-guided negative-pressure suction for the treatment of perinephric abscess: a case series

BackgroundDrainage is indicated in many patients with a perinephric abscess (PA). Surgical drainage is associated with trauma and slow recovery, while percutaneous drainage can be ineffective in some patients. We report on 11 patients with PA treated by percutaneous nephroscopy combined with ultrasound-guided negative-pressure suction under local anesthesia.MethodsThis case series included 11 PA patients operated on from January 2013 to June 2020. All patients received percutaneous nephroscopy combined with ultrasound-guided negative-pressure suction. Data, including operation time, volume of intraoperative blood loss, volume of intraoperative pus suction, time of postoperative drainage tube indwelling, time to restore normal body temperature, length of postoperative hospital stay, and intraoperative and postoperative complications, were collected.ResultsThe age of the patients was 59 (53–69) years. Eight, six, two, and two patients had hypertension, type 2 diabetes, rheumatoid arthritis, and renal calculi, respectively. The operations were successful forall11 patients. Eight, two, and one patients required one, two, and three channels, respectively, to clear their abscess. The average operation time was 44 (30–65) min, and intraoperative blood loss was 16 (10–20) ml. The volume of intraoperative pus suction was 280 (200–400) ml, time of postoperative drainage tube indwelling was 8.2 (6–12) days, and time to restoring normal body temperature was 0.8 (0.5–2) days. The average postoperative hospital stay was 9.8 (7–14) days. No severe intraoperative or postoperative complications occurred. The postoperative follow-up time was typically 4.8 (3–8) months, and there were no recurrences.ConclusionPercutaneous nephroscopy combined with ultrasound-guided negative-pressure suction might be a feasible method for treating PA.

Spontaneous Nephrocutaneous Fistula: A Rare Case Report and Our Experience

Spontaneous nephrocutaneous fistula is a very rare entity. The majority of causes are:post operative, calculus pyonephrosis, chronic pyelonephritis, renal infection, perinephric abscess, trauma. Renal tumor, xanthogranulomatous pyelonephritis (XGP) and renal tuberculosis. A case of spontaneous nephrocutaneous fistula in a 32 years young lady complaining of seropurulent discharge from the fistula over the right lumber flank for last 8 months is presented and discussed here. Brief history, physical examination. Ultrasonography. CT fistulogramwere performed which revealed an active fistula tract from skin to pelvicalyceal system of right kidney with a large impacted stone at right pelviureteric junction (PUJ). Patient was nondiabetic and negative for renal tuberculosis whereas renogram showed 32% relative renal function of the affected side. We performed exploration along with excision of the fistula tract, partial nephrectomy, pylolithotomy with DJ stenting and percutaneous nephrostomy (PCN). Follow up period was grossly uneventful. Currently, the occurrence of these types of spontaneous fistula is extremely rare except in patient with uncontrolled DM, neoplasia or immunosuppression in general. Bangladesh J. Urol. 2021; 24(2): 235-238

Percutaneous Nephrostomy in Complicated Urinary Tract Infections.

BackgroundThe study aimed to determine the various indications for percutaneous nephrostomy (PCN) primarily in patients with a urinary tract infection and to determine the various complications arising in these patients due to the procedure.Materials and methodsA retrospective study of five-year data based on registers of the Department of Urology was performed. Among 716 patients, 226 inpatient data were obtained, curated, and analyzed. Indications for PCN, the periprocedural complications, the PCN's duration, details of antibiotics, risk factors for UTI, development of acute kidney injury, and renal replacement therapy were recorded.ResultsPatients were mostly female (53.1%, n=120/226). Malignancy (n=109, carcinoma cervix=68/109) and nephrolithiasis (n=70) contributed to 79.2%. Infections such as pyelonephritis, renal abscess, perinephric abscess, and genitourinary tuberculosis were identified in 47. Infectious diseases were significantly associated with younger age, female gender, diabetes, and prior pyelonephritis. PCN was placed at a median of two days after admission, and bilateral PCN was placed in 36 (15.2%) patients. Hydroureteronephrosis (probably infected) was an indication for PCN in 164/226 patients. In 33 patients with an infectious disease, PCN was performed for an obstructed urinary system. One major and two minor complications gave a rate of 0.06% for patients with infections, which was less than the accepted threshold of 4%.ConclusionsWe intended to study the utility and problems with placing a PCN catheter in patients with complicated urinary infections. We conclude that PCN is a safe and effective procedure in urinary tract infections with obstructed drainage.

Renal abscess in children: Is size an important determinant in deciding treatment options?

Background: Renal abscess (RA) is rarely seen in the paediatric age group. The proposed management protocols are mainly derived from the adult series which may not be appropriate in children. Objective: In this retrospective analysis of cases with renal and perinephric abscesses, the objective is to correlate the clinical presentation, radiological findings and treatment options and also to propose a paediatric-specific practical management algorithm. Study design: This is a retrospective study of cases with renal and perinephric abscesses admitted between March 2012 and February 2020. The patients were reviewed for demographics, presentation, predisposing factors, laboratory investigations, imaging, management and outcome. Results: Analysis of 12 paediatric patients (13 renal units) with RA (median age 4 years) was done. Organisms were isolated in 8 of 12 (66.6%) patients with Gram-negative organisms being the commonest. On admission, all patients were started on empirical broad-spectrum antibiotics. Except for two patients who were critically ill with frank sepsis and had a tender renal lump, the rest of them were initially offered conservative management with intravenous antibiotics, and the response was reviewed after 48–72 hours. Of five units with abscess size of ⩽3 cm, two units (40%) responded to conservative management, while three units (60%) required intervention, and of eight units of size >3 cm, three units (37.5%) responded to conservative management and five units (62.5%) required intervention. None of the abscesses with perinephric collection (30.7%) responded to antibiotics and required intervention. Conclusion: A protocol based on the size of RA as recommended in most of the adult series may not be appropriate in the paediatric age group because of the differences in clinical presentation, predisposing factors and immune response. The clinical condition on presentation, response to antibiotic therapy and the presence of perinephric collection should be considered as an important determinant in deciding the need for intervention. Level of evidence: 4

Conservative treatment of emphysematous pyelonephritis and diabetes

Emphysematous pyelonephritis (EPN) is a rare but serious infectious disease caused by anaerobic bacteria that is characterized by necrotizing renal parenchymal infection and has a high mortality rate. The initial management of EPN includes resuscitation, antibiotics, management of any diabetes, and minimally invasive procedures, such as percutaneous drainage. Surgery is required in the most severe cases. Here, we describe a male patient with type 2 diabetes who presented with fever and abdominal pain and was diagnosed with EPN based on laboratory results and a computed tomography (CT) scan showing distension of the left kidney, several small air bubbles in the perirenal space, and thickening of the perinephric fascia. A subcutaneous insulin infusion and meropenem were administered. Repeat CT imaging 13 days later showed gas and necrotic tissue in the renal parenchyma. Therefore, CT-guided renal puncture was performed, and Escherichia coli was cultured from the drained pus. Antibiotic treatment was continued for 20 days after admission when the patient's kidney function and clinical symptoms had significantly improved. Sixty days after diagnosis, left nephrectomy was performed. The perinephric abscess was under high tension, and the left kidney was very soft. Histopathological examination revealed severe inflammation and necrosis of the renal pelvis, with fibrosis. The patient recovered well after surgery and remained alive 5 months later. EPN is a very rare disease with a high mortality rate and is more likely to occur in patients with diabetes. Early diagnosis and treatment of the infection are extremely important. For patients in whom gas and/or necrosis continue to accumulate after conservative treatment, we recommend nephrectomy.

IDF21-0242 Asymptomatic bacteriuria in patients with Type-2 Diabetes mellitus

Background: Asymptomatic bacteriuria is a common problem in patients with diabetes mellitus it is more common in females if untreated it leads to life threatening complications like pyelonephritis, emphysematous cystitis, perinephric abscess and renal papillary necrosis. Asymptomatic bacteriuria (ASB), believed to precede symptomatic urinary tract infection (UTI) in diabetes mellitus, has geographical variation in microbial pattern and risk factors.

Psoas Abscess as a Complication of a Perinephric Abscess

A 61-year-old woman with hypertension, hyperlipidemia, bilateral nephrolithiasis in 2008 status postbilateral lithotripsy, and left-sided pyelonephritis in 2020 complicated by subsequent Guillain-Barré syndrome managed with intravenous immunoglobulin (IVIG) presented to the emergency department with subacute progressive right-sided abdominal and flank pain. Her symptoms began 4 weeks prior to evaluation when she felt a sharp pain in her right hip and right lower quadrant, which was exacerbated by movement of her right lower extremity. She also endorsed cloudy urine.

Atraumatic Bilateral Renal Subcapsular Urinomas in a Young, Healthy Female

BackgroundUrinomas are rare and generally result from trauma to any part of the urinary collecting system. Appropriate imaging is crucial in the timely diagnosis and management of urinomas and for ruling out other etiologies such as subcapsular renal hematomas and perinephric abscesses. Case ReportA 31-year-old woman with no past medical history or known trauma presented to the Emergency Department (ED) with a week of right flank pain, abdominal pain, and intermittent fevers. On point-of-care ultrasound (POCUS), she was found to have a complex right perinephric collection, later confirmed with computed tomography (CT) imaging. She was treated with intravenous (IV) antibiotics and discharged after a 3-day hospital admission with instructions to follow up with Urology. A day later, she was readmitted with worsening bilateral flank pain and persistent fevers. Image-guided percutaneous aspirations of her bilateral perinephric fluid collections revealed both urine and blood. A right ureteral stent was then placed with ultimate resolution of her symptoms.Why Should an Emergency Physician Be Aware of This? Urinomas without history of trauma are rare and should be on the differential for patients presenting with flank pain and infectious symptoms. Urinomas or other expanding perinephric fluid collections can result in superimposed infection, rupture, secondary hypertension, and renal failure. Here, we present an atypical case of atraumatic bilateral renal subcapsular urinomas with hemorrhagic components in a young and healthy woman. Our case further outlines the utility of POCUS in the ED for the timely diagnosis and management of this disease process.

RENAL TRAUMA: PROFILE AND MANAGEMENT

AIMS AND OBJECTIVES: To determine the pattern of renal injuries in blunt trauma abdomen and management protocols. MATERIALS AND METHODS: All patients of blunt renal trauma above 15 years of age who fullled the inclusion criteria were included. Patients were studied for their management and outcomes. RESULTS: A total of 18 patients were enrolled who had blunt renal injury. Mean age was 28.72 years. Most common mode of injury leading to renal injuries were motor vehicle accidents i.e. 13 cases out of 18 (72.2%). Associated liver injury was present in 11 out of 18 cases (61%). Mean hospital stay was 10.76 days.. Hematuria occurred in 10 cases out of 18 i.e. 55.6%. There were 3 patients (16.7%) each of Grade I, Grade II, Grade III and Grade V renal injury. Grade IV renal injury was more common accounting for 6 cases out of 18 (33.3%). Grade I, II and III renal injury were managed conservatively. Out of 6 patients of Grade IV renal trauma, 5 were managed conservatively and one patient underwent angioembolization. Nephrectomy along with splenectomy was in one patient. complications like perinephric abscess formation, urinoma formation were noted CONCLUSION: Majority of the patients of blunt trauma renal injury can be managed conservatively. High Grade injuries may require surgery or angioembolization in selected cases.

Renal inflammatory myofibroblastic tumour presenting with a large retroperitoneal abscess

Inflammatory myofibroblastic tumour arising from the kidney is a rare occurrence. In this case report, we present a rare case of inflammatory myofibroblastic tumour arising from the kidney diagnosed after the presentation with a large retroperitoneal abscess for the first time in literature. A 55-year-old woman with diabetes mellitus presented to us with painful lump in the left lumbar region of the back for 1-week duration. On examination, there was a firm, diffuse lump in the left lumbar region of the back. Her inflammatory markers were high, but the serum creatinine and blood urea were within the normal range. Abdominal ultrasonography showed a distorted left kidney with a heterogeneous mass consisting cystic and solid components measuring approximately 7 × 9 × 8 cm in size. A contrast-enhanced computed tomography scan showed an 11 × 9 × 9 cm-sized low-density mass posterior to the left kidney with multiple contrast-enhancing septations which appeared posterior to but separate from the left kidney within the left renal fascia. There was breeching of the Gerota’s fascia with extension posteriorly up to subcutaneous tissue. Since the radiological opinion was in favour of a complex perinephric abscess, open drainage of the abscess was performed after failed attempts of ultrasound-guided drainage. The biopsy of the abscess wall was suggestive of a renal cell carcinoma and radical nephrectomy was planned. Due to tumour invasion, the radical nephrectomy was combined with a splenectomy and the specimen sent for histology. It showed an inflammatory myofibroblastic tumour or pseudotumour with the periphery showing ulceration and abscess formation. The patient had an uneventful recovery following surgery. Thus, we report the first case of renal inflammatory myofibroblastic tumour presenting with a large retroperitoneal abscess extending to the subcutaneous tissue plane. Final diagnosis was made only after radical surgery which was curative.

1233. Serious Toxicities During Antimicrobial Therapy for Disseminated Nocardia Infection in Solid Organ Transplant Recipients

BackgroundManagement of disseminated Nocardia (NC) infection in transplant recipients requires prolonged antimicrobial therapy. Treatment can be particularly challenging if NC is resistant to standard agents. Drug toxicities can further limit options. We present a series of transplant patients with multi-drug resistant, disseminated NC infection complicated by serious adverse reactions to sequential antimicrobials.MethodsThis is a prospective review monitoring response to treatment of disseminated NC as well as adverse events to therapies. ResultsThe first case is a 66-year old heart transplant patient who presented with fever and cough. Investigations revealed N. otitidiscaviarum lung lesion and multiple brain abscesses. Trimethoprim-sulfamethoxazole (TMP-SMX) and linezolid were started empirically. NC was fully susceptible to linezolid only, and intermediate to quinolones and tobramycin. Linezolid was switched to ciprofloxacin due to ongoing cytopenia, and dose of TMP-SMX was reduced due to renal insufficiency. Repeat brain MRI showed enlarging abscesses; regimen was changed to linezolid and moxifloxacin. Severe peripheral neuropathy led to linezolid discontinuation and initiation of high-dose doxycycline plus moxifloxacin. One year into therapy, he presented with a large aortic dissection. His long-term quinolone therapy was felt to be contributory. He underwent aortic stent placement and remains on doxycycline monotherapy. The second case is a 74-year old female renal transplant patient who presented with fevers. A perinephric abscess was found which grew N. farcinica resistant to floroquinolones and clarithromycin, and intermediate to doxycycline. Further imaging also revealed pulmonary and brain involvement. TMP-SMX was started but soon switched to linezolid due to acute kidney injury. One month later she presented with severe thrombocytopenia and subdural hematoma thought to be secondary to linezolid. She died despite surgery. ConclusionThis series illustrates challenges encountered in the treatment of disseminated NC infection in transplant recipients. Multidrug resistant NC coupled with serious toxicities of therapies often severely limits treatment options. Counseling patients and closely monitoring for adverse events is essential. Disclosures All Authors: No reported disclosures

Ultrasound guided tube drainage of perinephric abscess: Experience of 70 cases.

Objective: To determine the efficacy of ultrasound guided tube drainage of Perinephric abscess. Study Design: Observational study. Setting: Surgical Unit-II and Urology Ward Ghulam Muhammad Mahar Medical College Teaching Hospital Sukkur & Mustafia Hospital Sukkur. Period: February 2016 to January 2020. Material & Methods: 70 cases with Perinephric abscess underwent ultrasound guided tube drainage. Diagnosis was established by history, clinical examination, investigations like ultrasound & CT scan. Patients with emphysematous kidney & chronic sinus formation and with small abscess were excluded from the study. Patients were followed up for 4 weeks for complete regression of abscess cavity on ultrasound. Results: Out of 70 Patients 61.4% were male and 35% were female. 58.5% of the patients had right sided Perinephric abscess. Majority of the patients(42.8%) belonged to age group 41-50 years. 31.4% of the patients were diabetic. Clinically 95.7% of the patients reported with fever and 88.5% with flank pain. Ultrasound guided tube drainage was successful in 65(92.8%) while in 5(7.1%) patients it failed and open drainage was performed. Conclusion: Ultrasound guided tube drainage is an effective way to treat Perinephric abscess with very few minor complications as compared to open drainage.

A case report of perinephric abscess extending as psoas abscess

Iliopsoas abscess is a rare clinical entity. It is even more uncommon for psoas abscess to develop in association with genitourinary infections like perinephric abscess because of the retroperitoneal anatomy. Here we present an unusual case of a perinephric abscess extending as psoas abscess which was treated with computed tomography (CT) guided drainage.

Bilateral renal lymphangiectasia: A case report

Renal lymphangiectasia is a rare entity occurring both in children and adults with no specific age preference. It may be unilateral or bilateral and has no gender predilection. The clinical symptoms are non-specific ranging from no complaints with incidental diagnosis to pain abdomen. Radiological appearance may be mistaken with peripelvic cysts, renal cysts, and perinephric abscess, or collection. Hence, here lies the importance of familiarity with imaging appearance of this rare condition. We describe the case of a 35-year-old male who presented with pain abdomen. The radiological investigations revealed bilateral perinephric collections which led to the diagnosis of bilateral renal lymphangiectasia by exclusion, which was confirmed by aspiration of chylous fluid.

Role of Multidetector Computed Tomography in Evaluation of Renal Infections Hayam A. Abdellatif, Hager S. Sakr, El-Sayed M. El-Sayed

Background: Imaging plays a very important role in the diagnosis of renal infection. It assists diagnosis and differentiates between different types of renal infection. It also helps to detect and manage the associated complications through image-guided drainage and aspiration. Contrast-enhanced CT is the most useful study. A contrast-enhanced study is essential for a complete evaluation of patients with renal inflammatory disease to demonstrate alterations in the renal parenchymal perfusion and excretion of the contrast material, which occur as a result of the inflammatory process. Objective: To detect the role of multidetector CT in diagnosis of renal infection. Materials and methods: This prospective study was conducted on sixty patients. The study was carried out at Diagnostic Radiology Departments of Menoufia University Hospital. The patients were presenting with fever (< 38°C) mainly and loin pain. Results: From 60 patients with renal infection, 18 cases were diagnosed as pyonephrosis, 16 cases were diagnosed as renal abscess, 12 cases were diagnosed as pyelonephritis, 4 cases were diagnosed as xanthogranulomatous pyelonephritis, 4 cases were diagnosed as perinephric abscess, 2 cases were diagnosed as emphysematous pyelonephritis, 2 cases were diagnosed as fungal ball, 2 cases were diagnosed as urinoma. The mean age was (39.4 ± 15.7). Conclusion: Contrast enhanced computed tomography is a perfect diagnostic modality to assess the severity of inflammatory process and reaching the diagnosis of renal infection. It also helps to reach the cause, predisposing factors, associations, complications and the extent of the disease.

Fournier Gangrene as a Complication of a Perinephric Abscess After Kidney Transplant: A Case Report

Fournier gangrene is a progressive necrotizing infection of the external genitalia or perineum that constitutes a urologic emergency. Incidence of Fournier gangrene is rising because of population aging, increasing comorbidities, and widespread use of immunosuppressive therapy, including immunosuppressive regimens used in kidney transplants. This is a rapidly progressive and potentially lethal disease without treatment, and early recognition of the disease, proper management of the predisposing factors, and aggressive surgical debridement are the most essential interventions. We report a rare case of Fournier gangrene in the early postoperative period of a kidney transplant due to a perinephric abscess.

Percutaneous Nephrolithotomy Under X-Ray-Free Technique in Upper Urinary Stone Patients with Autosomal Dominant Polycystic Kidney Disease: Experience from a Large-Volume Stone Management Center.

Objectives: To present our large single-center experience in the management of autosomal dominant polycystic kidney disease (ADPKD) with total ultrasound (US)-guided percutaneous nephrolithotomy (PNL) and to evaluate the role of PNL under US in these patients. Patients and Methods: We retrospectively reviewed the charts of patients with ADPKD who underwent PNL from August 2011 to December 2019. A total of 56 patients were included in this study; all procedures were completed by the total US-guided technique. Demographic characteristics, operative parameters, and postoperative data were collected and analyzed. Results: Effective renal access was achieved in all patients. The mean stone size was 3.1 cm (range 1.7-6.5 cm). The initial stone-free rate was 70.6% (36/51); five patients underwent second-look PNL to remove residual stones. The other patients underwent oral medication therapy. No severe intraoperative complications occurred; one patient received selective embolization for bleeding on the contralateral side and one patient needed percutaneous drainage for perinephric abscess. Clavien I or II complications were seen in nine patients. Renal function was improved or stable in most patients; the condition of only one patient deteriorated after surgery. Conclusion: Total US-guided PNL is a safe and efficient treatment for kidney stones in patients with ADPKD; perioperative renal function was not adversely affected and complications were acceptable compared with patients in the general population.

Giant Angiomyolipoma Masquerading as Perinephric Abscess: A Diagnostic Conundrum

Renal angiomyolipomas are the most common benign tumours of the kidney accounting for up to 1% of all renal masses. Giant angiomyolipomas which have a size greater than 10 centimetres are rare entities with few cases reported in literature. Small angiomyolipomas are usually a symptomatic and increasing size correlates with symptomatology. These are usually incidentally detected or when symptomatic may present with an abdominal lump, flank pain or hemorrhage. Herein, we report a rare case of 45-year-old lady with giant angiomyolipoma with clinical presentation indistinguishable from perinephric abscess. The case is rare with regards to the large size of tumour and the discordant presentation unusual for an angiomyolipoma.

A study of asymptomatic bacteriuria in patients with diabetes mellitus

Diabetes is very common predisposing factor for UTI. The fact that asymptomatic bacteriuria is more common in females with diabetes as compared to males with diabetes. Asymptomatic bacteriuria (ASB) is defined as When a bacterial count of same species over10^5 per ml in mild stream clean catch specimen of urine on two occasion is detected without the symptom of urinary infection. Significant bacteriuria detected by urinary culture, without symptoms attributable to urinary tract like burning micturition, frequent micturition, urinary incontinence, urgency, painful micturition, suprapubic pain, flank pain or fever. Asymptomatic and symptomatic bacteriuria are more common in females with diabetes. Asymptomatic bacteriuria may be precursor for symptomatic bacteriuria. The UTI ranges from asymptomatic bacteriuria to lower cystitis, pyelonephritis, xanthogranulomatous pyelonephritis, renal abscess, perinephric abscess, and papillary necrosis. Asymptomatic bacteriuria seems to be non eradicable, recurring in case of diabetic females.