Perirenal Abscess Research Articles

An exercise in radiologic-pathologic correlation.

Improved technical methodology has increased the radiologist's diagnostic capability immeasurably in recent years. Nowhere is this more true than in the study of renal disease. Nephrotomography and aortography have permitted more subtle in vivo anatomic analysis, and, more recently, selective opacification of renal arteries has allowed visualization of even the very small renal vessels. The case this month illustrates a disease in which the renal angiographic findings are diagnostic, and the pathologic findings manifested in the radiographs should alert the radiologist to a potential complication that was present in this patient. Radiographic Findings A plain film of the abdomen of this 45-year-old man was obtained because of pain in the left flank. The margins of the left kidney and psoas were indistinct, but the findings were otherwise unremarkable. An excretory urogram (Fig. 1) demonstrates a normal right kidney and, again, the poor definition of the left renal and psoas margins. Contrast material is seen in the left ureter, but the remainder of the left upper collecting system is not visualized. The differential diagnostic possibilities considered at this time were renal neoplasm, perirenal abscess, and perirenal hematoma. Because of the possibility of a renal neoplasm and the patient's history of severe hypertension, aortography was performed. The findings led to bilateral selective renal arteriography, which showed that the main renal arteries were unremarkable. On the selective arteriograms (Figs. 2 and 3) collections of contrast material seen in the renal parenchyma were considered to be aneurysms. One on the right (Fig. 3) was considerably larger than the others. It should be noted that these abnormal dilatations of the renal arterial tree are rather uniform in size, about 1 to 5 mm, and are associated with the medium-size and small vessels exclusively. On the nephrogram phase of the right selective renal arteriogram (Fig. 4), persistent opacification of the aneurysms is noted, as well as scalloping of the renal contour, suggesting loss of renal cortex. Clinical History This 45-year-old Negro had intermittent pain in the left upper quadrant of the abdomen for the four weeks prior to admission to the hospital. During this time he was seen as an outpatient, and findings from the physical examination were within normal limits, with the exception of a low-grade fever (38° C.) and a blood pressure of 230/160. A chest roentgenogram showed minimal left ventricular enlargement but was otherwise within normal limits. Urinalysis demonstrated proteinuria, microscopic hematuria, and a few granular casts. The hematocrit was 45 per cent and white blood cells numbered 16,800. On the day of admission to the hospital he was brought to the emergency room in a confused state. At this time his blood pressure was 130/80, temperature 38° C, and the left upper quadrant was tender, although a mass could not be detected.

Nephrointestinal fistula. Reappraisal, review of literature, and report on two cases.

NEPHROINTESTINAL fistula fistula a relatively rare disease. It was described first by Hippocrates in 460 BC as a rupture of a renal abscess into the bowels. In 1841, it was clearly described by Roger as a complication of long-standing renal infection with probably perirenal abscess. In 1931, Mertz reviewed 29 cases, and more were added to the literature by Vermooten and McKeown; Wesson, Ratcliff, and Barnes; Rohrer and Findlay.¹More recently, Ellik and Getz²and Rost³reported three additional cases, and in 1958 Downs⁴brought the total number reported to 112. The reported incidence of nephrointestinal fistula has decreased in the last 20 years. This may be explained by more adequate urologic diagnosis and more efficient treatment of predisposing disease entities. The youngest patient reported in the literature was 18 months of age; the oldest was 81. The condition is more often encountered in younger or

Angiography in inflammatory space-occupying lesions of the kidney.

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).

Gas-containing perinephric abscess.

Perinephric abscess formation is an uncommon complication of urinary tract disease. This phenomenon is usually secondary to a cortical abscess or infection which has extended to the perirenal areolar tissue. It may also occur as a metastatic lesion, secondary to an inflammatory process elsewhere in the body. Beard (1) states that Staphylococcus is the usual offender in the metastatic type, while E. coli is commonly found when the abscess is due to a direct extension from the kidney. The finding of gas within such an abscess is unusual, a search of the literature having revealed only one case of perirenal gas collection (6) and one showing generalized gas formation within the kidney and perirenal structures (5). In one of these cases E. coli was found to be the causative agent; the other was due to Friedländer's bacillus. Gillies and Flocks (5) reported a case in a diabetic in which gas was initially demonstrated within the renal parenchyma, arranged radically as if distributed in the interstitial tissues rather than the collecting system. Twenty-four hours later, the gas was distributed throughout the renal and perirenal structures. This patient had a low urinary tract obstruction and E. coli was cultured from the blood, urine, and material removed at drainage of the kidney. Kindall (6) reported what appears to be the first case on record of gas within a perirenal abscess. Friedländer's bacillus was the causative agent, with an interesting complication of metastatic pulmonary abscesses appearing after drainage of the perirenal focus. Cultures of material removed bronchoscopically from the pulmonary abscesses also showed the Friedländer bacillus. The etiology of the perirenal abscess was not ascertained, although the possibility of a primary pulmonary infection could not be excluded, as an admission chest roentgenogram showed multiple pulmonary nodules. This patient had a high blood sugar on admission, with a return to normal following recovery. Pyelography after recovery also demonstrated an apparently normal urinary system. Madison (11) reported a case of a perinephric abscess due to a B. welchii infection but without the presence of gas within the abscess. In his series of cases, only one showed E. coli on culture; 25 per cent of his patients were diabetics. Case Report A 65-year-old, white female was brought to the hospital in a confused state and unable to give an adequate history. She complained of pain in the right abdomen, beginning about three days prior to admission; it was constant and equally severe in the upper and lower quadrants. She had experienced nausea since the onset of the pain and had vomited several times. (She vomited while being questioned; the vomitus was clear yellow, with no evidence of food or blood present.) Her bowel movements were said to be regular, but had been black for the past two days. She thought that she had had fever but no chills. No relevant past history was obtainable.

Spontaneous renoduodenal fistulas.

Renovisceral fistulas developing without surgical or traumatic intervention, the so-called spontaneous fistulas, are relatively uncommon. They are the result of an inflammatory process in the kidney which invades an adjacent viscus. There may first develop a perirenal abscess which ruptures into the viscus. For a general review of spontaneous renovisceral fistulas, the reader is referred to papers by Higgins and Hicken (3) and Mertz (4). The present communication deals specifically with spontaneous renoduodenal fistulas, which are particularly uncommon, only one case having been previously reported by American writers. A total of six cases have been found in the literature and these are briefly summarized below and in Table I. (A case described by Fernelius and cited by Higgins and Hicken (3) is omitted because the report is incomplete.) Rayer's description of a case of Campaignac's in 1839 is the earliest record of spontaneous renoduodenal fistula. The patient, a 45-year-old female, had a tender swelling in the right side which decreased in size following episodes of vomiting foul urine-like material. The fistulous communication was found at autopsy. Perry and Shaw (5) cite a case of Barlow's in which autopsy revealed hydatid cysts of the right kidney. These cysts had eroded into the duodenum. It was stated that the patient had vomited material corresponding to that found in the cysts. Perry and Shaw also cite a case of Turner's in which autopsy revealed pulmonary tuberculosis and tuberculosis of the right kidney, with fistulous communication between the kidney pelvis and duodenum. Bang (1) reported a tuberculous renoduodenal fistula, found at autopsy, in a 22-year-old female. Tuberculosis was present in almost every organ. A right ureteral stricture and right hydronephrosis were present. Another case secondary to tuberculosis was reported by Pulvertaft (6). The right kidney was pyonephrotic and contained many calculi. One calculus plugged a fistulous tract between the renal pelvis and duodenum. There was a severe scoliosis which, together with the infection and calculi, was thought to be responsible for the formation of the fistula. The first case in the American literature was contributed by Biondi (2) in 1935. His patient was a 28-year-old white female with symptoms of dyspepsia and vomiting soon after eating. Pain radiated from the right flank around anteriorly to the right costal margin and down to the groin. A gastro-intestinal study was reported as showing periduodenal adhesions, but the fistula was demonstrated only by retrograde urography. Nephrectomy was eventually done, and the pathologist's examination revealed tuberculosis of the kidney. The present case is reported as follows. A. M., a 62-year-old white male, was admitted to Cleveland City Hospital on April 23, 1948, suffering from chronic urethral strictures.

Perirenal Abscess with Gas Formation and Metastatic Pulmonary Abscesses Due to Friedlaender’s Bacillus—a Case Report

No AccessJournal of Urology1 Sep 1941Perirenal Abscess with Gas Formation and Metastatic Pulmonary Abscesses Due to Friedlaender’s Bacillus—a Case Report1 Lloyd Kindall Lloyd KindallLloyd Kindall More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)70955-XAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 1941 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byIreland G, Javadpour N and Cass A (2018) Renal Emphysema and Retention of Renal FunctionJournal of Urology, VOL. 106, NO. 4, (463-466), Online publication date: 1-Oct-1971. Volume 46Issue 3September 1941Page: 555-561 Advertisement Copyright & Permissions© 1941 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Lloyd Kindall More articles by this author Expand All Advertisement PDF downloadLoading ...

RENAL CARBUNCLE IN INFANCY

Renal carbuncle, so called because of its anatomic semblance to carbuncle elsewhere, is a localized massive suppuration within the kidney due to bacterial metastasis (usually staphylococcus), often produces marked toxemia, is rarely uncomplicated, is difficult to diagnose and, unrecognized or inadequately treated, entails a high mortality. Discussion of the lesion is found more often in surgical textbooks than in the literature; less than fifty cases have been reported. I have been unable to find a record of its occurrence in infancy. The two cases herewith reported, a boy and girl each admitted to the hospital at the age of 8 weeks with renal carbuncle and perirenal abscess and subsequently operated on, are unique because of the tender age of the patients. However, they are here described more especially because they forcibly demonstrate by specific example an insufficiently recognized principle of medical practice, namely, that infants and children are subject to

THE ETIOLOGY AND DEVELOPMENT OF GLOMERULONEPHRITIS

There are four well established types of renal disease that must be considered in a discussion of nephritis. A brief explanation of each of these will be given in order to establish the limitations of the group under discussion. <i>Pyelonephritis</i>.—This is an acute or chronic exudative inflammation distributed in patches throughout the kidneys, and extending from the cortex throughout the pyramids into the pelvis. It is caused by bacteria, usually staphylococci or colon bacilli. In most instances the bacteria are carried to the kidney by the blood; but in cases of obstruction of the lower urinary tract they may enter from the urine. In the earlier stages of a hematogenous infection, before there has been extension to the pelvis, the lesions are spoken of as abscesses. Extension of the infection to the capsule may produce perinephritis or perirenal abscess. Infection of a dilated pelvis causes pyonephrosis. The disease is frequently