Renal inflammatory disease


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UT Radiology Knoxville GU Lecture Series

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  • Figure 4a.  Severe unilateral acute bacterial pyelonephritis. (a) US image demonstrates a slightly enlarged right kidney that is otherwise unremarkable, belying the advanced disease. (b) CT scan shows the enlarged kidney with global decreased uptake of contrast material and multiple small low-attenuation foci from abscess pockets, findings that prompted nephrectomy. (c) Photograph of the resected gross specimen reveals multiple intrarenal abscesses that have begun to partially coalesce. Scale is in centimeters.
  • Figure 3b.  Acute bacterial pyelonephritis. (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis. (b) Color flow US image demonstrates diminished flow through the involved area.
  • 2 different cases of mass-like hyperechoic PN
  • Stone
  • Figure 7.  Acute bacterial pyelonephritis. (7) Unenhanced CT scan from a clinically documented case of acute bacterial pyelonephritis shows asymmetric enlargement and absence of the pyramids of the right kidney (cf the preserved pyramids [arrow] in the normal left kidney). Loss of the renal pyramids is a nonspecific marker for edema, which is more typically seen in obstruction related to calculi.
  • Figure 8.  Acute bacterial pyelonephritis. (8) Unenhanced CT scan demonstrates multiple, scattered, round and oval hyperattenuation foci within the left kidney, findings indicative of hemorrhagic acute bacterial pyelonephritis.
  • PN; right is 5 hours later.
  • Figure 11.  Acute bacterial pyelonephritis caused by hematologic seeding in a patient with Staphylococcus aureus endocarditis. CT scan demonstrates peripheral low-attenuation lesions (arrowheads) that are maturing into small abscess cavities. In such cases, blood and urine cultures grow the same organism.
  • left column: collecting duct carcinoma
    Middle column: top is urothelial carcinoma, bottom is lymphoma
    Right column: infarct following trauma
  • US – immature abscess
  • Emphysematous pyelonephritis represents a severe life-threatening infection of the renal parenchyma with gas-forming bacteria. Underlying poorly controlled diabetes mellitis is present in up to 90% of patients who develop emphysematous pyelonephritis. Urinary collecting system obstruction from pathologic conditions such as stone disease, urothelial neoplasm, or sloughed papilla (31) is also commonly present. Patients present clinically with varying degrees of renal failure, lethargy, acid-base irregularities, and hyperglycemia. Rapid progression to septic shock may be seen, and emphysematous pyelonephritis carries an overall mortality rate of approximately 50% (32). Flank pain and, rarely, crepitus over the lower back or thigh may be seen at physical examination (33). E coli is the causative bacterial source in approximately 70% of cases, with Klebsiella, Candida, and Pseudomonas species isolated less frequently
  • Bilateral emphysematous pyelonephritis in a 72-year-old man who presented with fever, chills, and near syncope. Abdominal radiograph reveals extensive, radially oriented air within and surrounding the kidneys (black arrows). Air is also seen within the left renal collecting system (white arrows).
  • Emphysematous pyelonephritis in a 45-year-old woman. (a) Abdominal radiograph obtained with the patient upright demonstrates a 2-cm calcification overlying the region of the left ureteropelvic junction (arrow) and several smaller calcifications overlying the lower pole. Note also the mottled collection of gas bubbles in the region of the left lower renal pole (arrowheads) and the large air-fluid level within the upper pole (*). (b) Contrast-enhanced excretory-phase CT scan obtained at the same level as a demonstrates enlargement of the left kidney with persistent parenchymal enhancement relative to the normal right kidney. Note the air-fluid and debris level (*) within the upper pole, a finding that corresponds to the radiographic finding. A large obstructing ureteral stone (arrow) and perinephric inflammatory changes are also present. (c) Photograph of the cut gross specimen reveals diffuse parenchymal necrosis.
  • Emphysematous pyelonephritis in a 60-year-old diabetic man with several days’ history of nausea and general malaise. (a) Longitudinal US image of the left kidney demonstrates normal findings. (b) Longitudinal US image of the right kidney shows foci of high-amplitude echoes (long arrow) with associated posterior dirty shadowing (short arrow). (c) Corresponding contrast-enhanced CT scan obtained during the late excretory phase shows multiple parenchymal gas collections (arrows
  • Left: 65-year-old woman with cirrhosis and portal hypertension in the right kidney Initial transverse postcontrast CT scan shows the gas-fluid level (arrow) inside the dilated calyx. (c) Transverse postcontrast CT scan obtained at a level similar to that in b 3 weeks after medical treatment shows the disappearance of both gas and dilatation of the calyces.
    Right: CT scans in a 72-year-old man with staghorn calculi in the left kidney
  • H
  • Figure 23a.  Xanthogranulomatous pyelonephritis. (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi, with distention of the right collecting system secondary to inflammatory debris. (b) US scan also shows the dilated collecting system (arrowheads) and a shadowing calculus (arrow). (c) Photograph of a cut specimen clearly depicts a complex, milky infiltrate that fills and expands the collecting system.
  • During primary infection, TB reaches both kidneys and forms microscopic granulomas in cortex where remains innocuous, potentially forever. However if reactivation occurs, usually in one kidney. Reactivation begins in medulla, where microabscesses form in the papilla; where they can then rupture into the calyces, spreading down the collecting system. Destruction, fibrosis, calcifications and obstruction are components of the process.
  • 49 yo female with flank pain and fever – bilateral malakoplakia
  • 2 cases of candida infection
  • Renal inflammatory disease

    1. 1. Renal Infectious/Inflammato ry Disease Jud Gash, MD
    2. 2. Outline         Pyelonephritis Renal Abscess Emphasematous Pyelonephritis Pyonephrosis Xanthogranulomatous Pyelonephritis TB Renal Malakoplakia Other Infection
    3. 3. Pyelonephritis  Predisposition  Most cases similar to lower UTI causes (esp intercourse)    About 20-30:1 cystitis to PN Female, reflux, obstruction, stones, diabetes, stasis (congenital anomalies, diverticula), pregnancy Clinical   Gram negatives (E coli, Proteus, Pseudomonas, etc.) Flank pain and tenderness, fever, N/V, signs of cystitis
    4. 4. Pyelonephritis  Imaging   Usually not necessary (uncomplicated PN) Reasons to image Uncertain diagnosis  Severe symptoms  Atypical clinical situation   men, unresolving, children, diabetics Role out obstruction  Evaluate source in recurrent pyelonephritis    May see incidentally Note: imaging of PN/UTI in children whole separate topic
    5. 5. Pyelonephritis  Pathophysiology  Ascending Infection   Adhesions and Endotoxins Ureteropyelitis    Pyelonephritis    Thickened, enhancing Urothelium Ureteral “ileus” Access/spread via papilla Wedge shaped and patchy Rarely hematogeneous   Staph Bilateral
    6. 6. Ultrasound  Role Detect Complications    Pyonephrosis; abscess Predisposing factors Scarring     Imaging Normal (75%?) Enlargement Loss of corticomedullary junction Decreased Echogenecity   Hyperechoic (hemorrhage)   Focal or diffuse Focal Hypoechoic area on Power Doppler
    7. 7. Severe unilateral acute bacterial pyelonephritis Craig W D et al. Radiographics 2008;28:255-276
    8. 8. Craig W D et al. Radiographics 2008;28:255-276
    9. 9. Pyelonephritis Radiographics. 2000;20:215-243 Craig W D et al. Radiographics 2008;28:255-276
    10. 10. Pyelonephritis  CT  Noncontrast  Normal Nephromegaly  Perinephric stranding  Loss of hyperdense pyramids  Hyperdensities (hemorrhage)  Thickening of urothelium  Mild ureteral dilation Contrast  Wedges of hypoattenuation (edema, obstruction, and vasospasm)  Dense on delayed  Striations (focal, diffuse) May be abnormal for days or weeks Role        Diagnosis/alternative diagnosis Acute complications Underlying predispositions (CTU)
    11. 11. ED – flank pain (no stone seen)
    12. 12. Pyelonephritis  DDX      PN Recent stone passage Non-stone obstruction (clot, fungus ball, iodinovir) Acute vascular lesion (RA, RV occlusion) So, non-contrast findings nonspecific.   Clinical exam/UA/hydro should allow distinction Consider contrast if unclear RadioGraphics 2004;24:S11-S28
    13. 13. Craig W D et al. Radiographics 2008;28:255-276
    14. 14. Craig W D et al. Radiographics 2008;28:255-276
    15. 15. Pyelonephritis RadioGraphics 2004;24:S11-S28
    16. 16. Pyelonephritis Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
    17. 17.  Acute bacterial pyelonephritis caused by hematologic  seeding in a patient with Staphylococcus aureus  endocarditis Craig W D et al. Radiographics 2008;28:255-276
    18. 18. Pyelonephritis – DDX (3 I’s) Radiographics. 2000;20:215-243
    19. 19. Pyelonephritis  Focal Pyelonephritis Replaces old terms (FLN, ABN, etc.)  May be pre-abscess state  Now focal or diffuse pyelonephritis  Imaging   Focal mass-like lesion can mimic tumor
    20. 20. Complications of Pyelonephritis  Acute  Abscess      Renal Perinephric Emphysematous PN Pyonephrosis Chronic    Scarring/Atrophy XGP/malakoplakia Papillary Necrosis
    21. 21. Abscess  Etiology PN which proceeds to tissue necrosis and liquefaction  More likely with obstruction, diabetes (75% of all abscesses), stone disease  Normal kidneys or superinfect pre-existing lesions (cysts, diverticula, RCC)  Can spread to perinephric space 
    22. 22. Abscess  Imaging  US   CT    Rounded, thick wall cystic mass with debris Rounded cystic lesion with enhancing wall Surrounding inflammatory changes Microabscesses  Small, often multiple areas in the setting of PN RadioGraphics 2004;24:S11-S28
    23. 23. Perinephric Abscess  Usually secondary to pyonephrosis  Less commonly in unobstructed PN Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
    24. 24. Emphysematous Pyelonephritis      Aggressive form of PN with necrosis, vascular compromise and air production Rare life threatening form urologic emergency 90% diabetics (poorly controlled) Obstruction common (must exclude) Adults   Rare, if ever, seen in pediatrics Clinical presentation   Fever, flank pain, lethargy, renal failure, septic shock Usually gram negatives, esp. E. Coli
    25. 25. Emphysematous Pyelonephritis  KUB    Gas collections Renal Enlargement Stones Radiographics. 2002;22:543-561
    26. 26. Emphysematous Pyelonephritis
    27. 27. Emphysematous Pyelonephritis
    28. 28. Emphysematous Pyelonephritis
    29. 29. Emphysematous Pyelonephritis Radiographics. 2002;22:543-561
    30. 30. Emphysematous Pyelonephritis  US Hyperechoic dirty shadowing  DDX: nephrocalcinosis and nephrolithiasis 
    31. 31. Emphysematous Pyelonephritis Radiographics. 2002;22:543-561
    32. 32. Emphysematous Pyelonephritis  CT Parenchymal air – bubbles, linear  Severe inflammatory changes  Look for obstruction  Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
    33. 33. Emphysematous Pyelonephritis  Treatment Nephrectomy – traditional gold standard  If more limited, milder form – percutaneous drainage/relief of obstruction and antibiotics  Radiographics. 2002;22:543-561
    34. 34. Emphysemtous pyelitis    Gas in collecting system Same epidemiology as EPN Better prognosis  Relief of obstruction/ABX
    35. 35. Emphysemtous pyelitis Air In Collecting System    Emphysematous Pyelitis Fistula Iatrogenic Radiology. 2001;218:647-650
    36. 36. Pyonephrosis   Obstructed, infected kidney Cause of obstruction   Stones (rarely other: Conj UPJ, tumor) Emergency Urosepsis  Renal destruction  XGP (chronic)   Treatment  Drainage (perc neph/stent and antibiotics)
    37. 37. Pyonephrosis  US     Large, hypoechoic kidney Hydronephrosis Echogenic debris Fluid – Fluid Level Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
    38. 38. Pyonephrosis – 4 cases
    39. 39. Pyonephrosis  CT    Findings of infection Findings of obstruction Hypedense/debris in collecting system   Thick pelvic pelvic wall (2-5mm)    >30 hu (Note: 50%<15hu) 75% (Note: 10% of uninfected obstruction) Emphysematous pyelitis in 10% Aspirate Urine
    40. 40. Chronic Pyelonephritis   Controversial Pathophysiology Findings Renal Scarring  Calyceal Clubbing  At Renal Poles   DDX  Renal infarcts
    41. 41. Xanthogranulomatous Pyelonephritis (XGP)   Disorder immune response in setting of chronic infection, often with obstruction and stones (ie pyonephrosis) Pathophysiology     Stone leads to obstruction Caliectasis (peripelvic fibrosis limits pelviectasis). Infection leads to parenchymal destruction and replacement with lipid laden macrophages Treatment  nephrectomy Radiographics. 2000;20:215-243
    42. 42. Xanthogranulomatous Pyelonephritis (XGP)  Key points  Middle age women with longstanding infection/stones   DM in only 10% Triad Nonfunction  Renal enlargement    Caliectasis with less pelviectasis, parenchymal loss Stones (90%)  Staghorn, exploded
    43. 43. Xanthogranulomatous Pyelonephritis (XGP)  KUB   “exploded” staghorn with large renal shadow US Caliectasis (massive) with debris  Stones  Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
    44. 44. Xanthogranulomatous Pyelonephritis (XGP)  CT   “Bear Claw” Massive caliectasis (without pelviectasis)    Not fluid though Parenchyma enhances (not function) Stones Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
    45. 45.   Xanthogranulomatous pyelonephritis Craig W D et al. Radiographics 2008;28:255-276 ©2008 by Radiological Society of North America
    46. 46. Xanthogranulomatous Pyelonephritis (XGP) Radiographics. 2000;20:215-243 Radiographics. 2000;20:215-243
    47. 47. Xanthogranulomatous Pyelonephritis (XGP)  Other Findings     Extrarenal Extension Nodes Fistula Segmental
    48. 48. Tuberculosis  Pathophysiology      Renal cortical deposition occurs in primary infection Reactivation (one kidney) in medulla Descending process Destruction, fibrosis, calcification, obstruction Dx  Culture (sterile pyuria)
    49. 49. Tuberculosis  KUB Diffuse or scattered renal calcifications (25%)  Often small renal shadow  “putty kidney”  Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
    50. 50. Tuberculosis  CTU (IVP)  Renal       Ureter      Moth eaten, fuzzy calyx with papillary necrosis Infundibular, pelvic fibrosis (purse string pelvis) Calyceal/pelvic obstruction (hydrocalyx, phantom calyx) Renal nonfunction (autonephrectomy), scarring calcification (putty kidney) Note: renal changes mimic TCC Ulcerations and irregularity; sawtooth (early) Multiple strictures; corkscrew (later) Short, strait, aperistaltic (latest) Calcifications (DDX: schistosomiasis) Bladder involvement is very late AJR 2005; 184:143-150
    51. 51. Renal Parenchyma Malakoplakia (RPM)   Inflammatory condition to chronic E. coli infection Disordered macrophage response to bacterial phagocytosis   Entire GU tract can be affected    histologic hallmark is basophilic inclusions (MichaelisGutmann bodies) within large eosinophilic macrophages (von Hansemann histiocytes) Most commonly urothelial plaques (bladder esp.) RPM occurs uncommonly Usually middle age women with h/o chronic infection  Flank pain, fever
    52. 52. Renal Parenchyma Malakoplakia (RPM)  Findings: Bilateralor unilateral  Focal, multifocal or diffuse  infiltrating masses  Renal pelvis involvement may occur  Calcifications uncommon  Radiographics. 2000;20:215-243.)
    53. 53. Fungal Disease     Usually immunocompromised (DM, steroids, HIV, etc.) Candida most common Any portion of urinary tract Imaging   Changes of PN, abscess Fungus ball in collecting system  Non-stone (echogenic) filling defect  DDX: sloughed papilla, tcc, clot Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
    54. 54. Outline         Pyelonephritis Renal Abscess Emphasematous Pyelonephritis Pyonephrosis Xanthogranulomatous Pyelonephritis TB Renal Malakoplakia Other Infection