2. CASE
A 49 year old female presented with 3 year history of flank
pain associated with terminal dysuria and hematuria ,
Diabetes Mellitus type-2 recently diagnosed , sought
consultation at a local hospital ,was then referred to spmc
for further evaluation and management.
3. PATIENT’S DATA
Name: A.J.
Age: 49 yr old.
Sex: Female.
Civil status: Married.
Religion: Roman Catholic.
Address: PRK VILLEGAS ZONE III (POB). KORONADAL CITY.
Reliability: 90%
5. HISTORY OF PRESENT ILLNESS
3 year prior history of flank pain right, associated with terminal dysuria and hematuria , no
consultation was done , no medication was taken , in the interim patient tolerated the condition .
1 month prior patient sought consult at a local hospital due to persistent flank pain , was admitted for
5 days ,with unrecalled treatment which provided temporary relief .
On the day of admission still with persistence of flank pain right , with a pain scale of 6/10,
sharp,non radiating , associated with terminal dysuria and hematuria,urgency,urinary frequency ,
vomitting 6 episodes per day ,30 ml per episode of previously ingested food ,no other symtoms like
fever ,chills ,diarrhea were present at the time ,
persistence of the symptoms prompted patient to seek consultation .
6. Diabetes Mellitus type-2, recently diagnosed, Insulin requiring-
Patient has a hisotry of recurrent urinary tract infections in the year 2019,2021 and
2022. Was treated with unrecalled antibiotics.
No Hypertension
No Asthma
Vaccinated - 2 doses Pfizer .
Hospitalization: 1 month prior was hospitalised at a local hospital for 5 days due to
persistent flank pain .
Surgery: s/p remova, of abcess ,left flank (2015)
Trauma: No history of any trauma or injury noted.
Allergies: Patient is not allergic to food or any medications.
PAST MEDICAL HISTORY
7. FAMILY HISTORY
Hypertension - Mother , Sister
Mother died because of pneumonia
No history of cardiovascular disease in family
No history of cancer in family
No history of asthma
No history of heredofamilial diseases
8. PERSONAL AND SOCIAL HISTORY
She follows Filipino foods like rice,fish and Snacks as biscuits.
She is a house wife
She has completed education level upto 1st year college
Non smoker
Non alcoholic beverage consumer
There is no recent travel history
She usually listens to music and reads the bible to cope up with stress.
10. PHYSICAL EXAMINATION
GENERAL: Awake, Alert and anxious
SKIN: jaundice(-), rashes(-).
HEENT: (-)Alopecia, (-)Lesions or lumps over head, No gross deformities,
Pink palpebral conjunctiva, Anicteric sclerae, (-)Nasal Congestion, (-)epistaxis,
(-)Sore Throat, (-)Oral Ulcers., No cervical lymohadenopathy , no lumps or masses paplpated im the
cervical region
THORAX /CHEST:
•Inspection: Symmetric equal chest expansion ,respiratory movements are full .no apparent effort or use of
accessory muscles for inspiration
•Palpation: No tender of sternum ,ribs or costochondral joints.
•Percussion: Resonant sound heard on percussion ,low pitched and long duration
•Auscultation: symmetric and vesicular with inspiration being louder than expiration low pitched, no audible
adventitious sounds
11. PHYSICAL EXAMINATION
CARDIOVASCULAR:
•Inspection: Adynamic precordium
•Palpation : No heaves or thrills were noted
•Auscultation:Normal heart sounds , distinct S1 and S2 .No murmurs heard in systole or diastole when patient
is supine or in left lateral decubitus position.
ABDOMEN:
Inspection: Soft, flabby, non-distended abdomen
Auscultation: Normoactive Bowel Sounds
Palpitation: (+) tenderness on hypogastrium
Percussion- (-) cva tenderness
Extremities - No edema, No swelling ,CRT<2seconds
12. PHYSICAL EXAMINATION
Cranial Nerves:
CN 1- normal
CN 2- Normal visual acuity 20/20
CN 3,486- No nystagmus, nor ptosis noted
CN 5-Strong muscle contraction
CN 7-symmetric and no abnormal movements
CN 8- No hearing loss
CN 9&10- No difficulty in swallowing, normal gag reflex
CN 11- No atrophy or fasciculations
CN 12- Good articulation, no atrophy or fasciculation
13. IMAGING
Chest X-ray
Lungs are clear
Heart is not enlarged.
Great vessels are not unusual.
Diaphragm and costophrenic angles are intact.
No other remarkable findings.
Normal Chest findings.
17. LAB RESULTS 01/11/2023 CBC
• Hemoglobin - 119.0 g/L(low) (123- 153) normal range
• Hematocrit - 0.37 (0.35- 0.45) normal range
• RBC count - 4.13 x 10^6/uL (low) (4.5 -5.1) Normal range
• WBC count - 12.52 x 10^3/uL (high) (4.0-11.0) normal range
• Neutrophil - 85 % (high) normal (44 -68)
• Lymphocytes- 8.0 % (low) normal (20-40)
• Monocytes -5.0% Normal range (2-10)
• Eosinophils - 2% normal range (1-6)
• Basophils - 0 % normal range (0-1)
• Platelet - 241x 10^3/uL. Normal (150-400)
• MCH - 28.8pg normal (25.60 - 32.20)
• MCHC -32.6 g/dL normal (32.20 -35.50)
• MCV- 88.4 fl. Normal (79.40- 94.80)
18. PROTHROMBIN TIME
• PT patient - 16.5 seconds (H) Nor : 11.5 - 14.3
• PT Inr - 1.26
• PT activity - 71.0
• PT control - 14.5 seconds Nor : 12.0 -16.0
• APTT - 27.4 seconds Nor : 27.0 - 34.0
• APTT control - 30.9 seconds Nor : 26.0 - 34.0
19. LAB RESULTS 01/11/2023
Clinical chemistry
▪ Blood Urea nitrogen - 6.39 mmol/L normal range ( 2.9 -7.1)
▪ calcium - 2.05 mmol/L (low) normal range( 2.20 - 2.65)
▪ creatinine - 110.5 umol/L (high) normal range( 49 -90)
▪ potassium -3.97 mmol/L normal range( 3.50 -5.10)
▪ Magnesium - 0.69mmol/L (low) Normal range (0.77- 1.03)
▪ Sodium - 141.00 mmol/L normal range ( 136.00 - 146.00)
▪ Albumin - 36.70 g/L. normal range ( 35.00 - 52.00)
20. LAB RESULTS
▪ SEROLOGY AND IMMUNOLOGY
▪ COVID-19 ANTIGEN RAPID TEST
Result : negative
SAMPLE: nasopharyngeal Kit used: SD recommended for confirmatory testing with rt-pcr sample
▪ Polymerase chain reaction(PCR)
▪ COVID 19 rt-pcr test.
Result; Viral RNA not detected
21. SALIENT FEATURES
Patient is a 49 year old ,female .
Prsented with a cheif complaint of flank pain , right .
3 year -chronic flank pain with terminal dysuria and hematuria
(+) urgency ,(+) frequncy (+) vomiting 6 episodes.
Patient co morbid - DM type 2
History of recurrent UTI
s/p abcess removal left (2015)
Family history of Hypertension
(+) untentional weight loss 13 kgs in the past 1 year
(+) fatigue
non-healing wound with purulent discharge (left flank)(3*3cm).
Costovertebral, angle tenderness.
creatinine - 110.5 umol/L (high)
BUN - 7.69 mmol/L (high)
Hba1c -7.6 %
WBC - 12.52 (high) - neutrophilic predominance 85%
22. PRIMARY IMPRESSIONS
POORLY FUNCTIONING KIDNEY LEFT , SECONDARY TO
XANTHOGRANULOMATOUS PYELONEPHRITIS LEFT ,
OBSTRUCTIVE UROPATHY RIGHT ,SECONDARY TO
PELVOLITHIASIS RIGHT .
23. DIFFRENTIAL DIAGNOSIS -1 - RENAL CELL CARCINOMA
RULE IN RULE OUT
Flank pin with hematuria Renal mass and hematuria is absent
Dysuria noted Incidence is more common among 64
year old
Costovertebral angle tenderness noted Tends to predispose males more
Weight loss noted
24. DIFFRENTIAL DIAGNOSIS – 2 – PAPILLARY RENAL CELL
CARCINOMA
RULE IN RULE OUT
Flank pain noted Absence of unexplained cancerous
tumors
Hematuria noted Males are affected more
Weight loss noted Average age of onset is 64 years
25. DIFFRENTIAL DIAGNOSIS – 3 – PYONEPROSIS
RULE IN RULE OUT
Flank pain noted Fever is absent
Diabetes noted (risk factor) diabetes Asymptomatic bacteria is absent
Leukocytosis noted
Elevated BUN and creatinine levels
were noted
26. DIFFRENTIAL DIAGNOSIS – 3 – RENAL TUBERCULOSIS
RULE IN RULE OUT
Hematuria Abdominal or pelvic pain
Urinalysis frequency Abdominal mass
Dysuria
27. FINAL DIAGNOSIS
POORLY FUNCTIONAL KIDNEY LEFT , SECONDARY TO
XANTHOGRANULOMATOUS PYELONEPHRITIS LEFT ,
OBSTRUCTIVE UROPATHY RIGHT ,SECONDARY TO
PELVOLITHIASIS RIGHT. DIABETES MELLITUS TYPE -2
INSULIN REQUIRING
28. MANAGEMENT
Xanthogranulomatous pyelonephritis (XGP) is a surgically
managed disease that is treated with either nephrectomy or,
in rare circumstances, partial nephrectomy. Antibiotics are
used in all cases, but medical care rarely suffices for
treatment.
Extirpation is necessary because the disease occurs or
results in an infected, nonfunctioning kidney. Nephron-
sparing surgery will continue to be explored, provided that
viable renal parenchyma is demonstra
29. MANAGEMENT
Admit the patient
•For therapeutics give IVF PNSS 1L 60cc/hr
•Tramadol is given for the pain (50 mg per ampule )
•Plan: Nephrectomy left , flank exploration left,cystoscopy, DJ stunting right
•Vital signs monitored every 4 hours with input and output q shifts
•CBC monitored pre meals three times a day
•Follow diabetic diet
30. MANAGEMENT
Extirpating is necessary as disease occurs in infected non functioning kidney
•Contraindications to surgical therapy are those consistent with major operations and intolerance to
anesthesia , uncorrected coagulopathy , severe connective tissue disorders
•Annual imaging of contra lateral urinary tract is important
•Evaluation of lower urinary tract and voiding dysfunction is important in such patients
•Antibiotic therapy: appropriate prophylactic antibiotic should be administered before operative
intervention
•Choice of antibiotic should be geared towards the identity and sensitivity of the organism
•For surgical options nephrectomy is considered as the standard criterion for the treatment
31. MANAGEMENT
• Cases are complicated due to the involvement of the local organs
• The goal is to remove the granulomatous tissue and if not removed it may
lead to cutaneous fistulae
• Laparoscopic nephrectomy is feasible only for certain cases .
• Perioperative considerations should appropriately be accomplished and the
best accomplished is the CT scanning .
• Administer bowel preparation and pre operative antibiotics
• Since the patient is diabetic establish control of hyperglycemia preoperativel
• Intraoperatively flank approach through the appropriate intercostal and sub
costal space is desirable to avoid contamination of the peritoneum .
32. MANAGEMENT
◼ The basic principle of nephrectomy is to apply to the
extirpation of renal xanthogranulomatous
pyelonephritis . All involved tissues must be
removed.liberal irrigation with antibiotic fluid is
performed and suction drain is left in place .
◼ Immediate post operative care consistent with
standard nephrectomy should be done . Watch for
signs of sepsis and encourage early ambulation .
33. CASE DISCUSSION:- INTRODUCTION AND DEFINITION
Xanthogranulomatous pyelonephritis is an uncommon chronic destructive granulomatous
process of renal parenchyma in association with long-term urinary tract obstruction and
infection. Almost all patients are symptomatic and the most common symptoms are flank or
abdominal pain, lower urinary tract symptoms, fever, palpable mass, gross hematuria, and
weight loss. The common laboratory findings are leukocytosis and anemia. Urine cultures
most often reveal Escherichia coli and Proteus mirabilis . Computed tomography is the
mainstay of diagnostic imaging for xanthogranulomatous pyelonephritis. Imaging studies
may demonstrate diffuse or focal form.
34.
35. The kidney is usually nonfunctional
CT findings include a staghorn calculus with
contraction of the renal pelvis, multiple rounded
hypoechoic foci in the kidney, enlargement of the
kidney, and perinephric inflammation or abscesses. The
arrangement of multiple rounded hypoechoic foci
around the contracted renal pelvis has been described
as the bear paw sign and is considered characteristic of
XGP
36. EPIDEMIOLOGY
• The incidence of XGP varies from 0.6% to 1% of all cases of renal infections.
• The disease can occur in all age groups but is 4 times more common in women than in
men, usually in their fifth and sixth decade of life.
• There is no specific race predilection. in most patients, a unilateral kidney is involved,
bilateral involvement can rarely occur in a few cases.
• Both the kidneys are affected with equal frequency.
• XGP is often associated with urinary tract obstruction, infection, nephrolithiasis, diabetes,
and/or immunocompromise
37. ETIOLOGY
◼ The exact etiology of xanthogranulomatous pyelonephritis (XGP) is unknown,
◼ but it is generally accepted that the disease process requires long-term renal obstruction and infection.
◼ As previously stated, XGP is most commonly associated with Proteus or Escherichia coli infection;
Pseudomonas species have also been implicated
◼ Increased riskin diabetics
◼ Following recurrent UTIs
38. PATHOPHYSIOLOGY
• The exact pathophysiology of XGP is unclear.
• The mechanism involved in the pathogenesis of XGP is nephrolithiasis leading to chronic
obstruction and infection.
• An inflammatory disorder that may occur due to a defect in the degradation of bacteria by a
macrophage.
• The disease is characterized by the destruction and replacement of renal or peri-renal tissue
with granulomatous tissue containing lipid-laden macrophages. However, the accumulation of
lipids and cholesterol in the lesion is not well understood.
• It starts from the renal pelvis and calyces spreading to the renal parenchyma and finally to the
adjacent organs if left untreated.
• Adjacent organs such as the liver, spleen, duodenum, pancreas, and great vessels can be
involved in a severe form of XGP.
41. PATHOGENESIS
Bacteria: low virulence
septicemia uncommon
Interrelated factors:
1.venous occlusion &hemorrhage
2.abnormal lipid metabolism
3.lymphatic blockage
4.failure of antibiotics in UTI
5.altered immunological competence
6.renal ischemia
42. PATHOLOGY
◼
◼ The kidney is massively enlarged normal contour
◼ Two types
◼ Diffuse : 80% entire kidney is involved
◼ Segmental :20% only the
◼ parenchyma surrounding one or more calyces or one
pole of a duplicated collecting system
43. ◼On section: Macroscopically:
◼Kidney demonstrate:
◼Nephrolithiasis
◼peripelvic fibrosis
◼calyceal dilatation filled with pus
◼papillary necrosis
◼multiple parenchymal abscess (advanced disease) with
◼yellowish tissue &PUS
◼cortex is thin often replace by Xantho granulomatous tissue
◼capsule is thickened
◼inflammatory extension into peripelvic & parapelvic space is common
44. MACROSCOPICALLY
◼ Yellowish nodules line the calyces and surrounds parenchyma, abscesses
◼ Contains dark sheets of lipid laden macrophages (foamy histiocytes with
small dark nucleus and clear cytoplasm
◼ Intermixed lymphocytes ,giant cells and plasma cells
46. BACTERIOLOGY & LAB DIAGNOSIS
*Proteus (most common organism involved)
*Ecoli(also common)
*Anaerobes
*10% (mixed infections)
URINE ANALYSIS
Shows pus &protein
BLOOD TESTS
*Anemia
*hepatic dysfunction(50%)
*Azotemia or frank renal failure uncommon
47. RADIOLOGICAL FINDINGS
*50-80% show classic triad
-unilateral renal enlargement
-little or no function
-large calculus in renal pelvis
EXCRETORY UROGRAPHY:
-delayed function
-Hydronephrosis (massive)
-smaller calcification with in the mass
48. RETROGRADE PYELOGRAPHY:
◼ point of obstruction
◼ dilatation of pelvis &calyces
◼ ulcerated pyelocalyceal system with multiple irregular filling defect (if extensive parenchymal damage)
USG:
◼ demonstrate global enlargement of the kidney.
◼ normal architecture is replaced by multiple hypoechoic fluid filled masses correspond to debris filled ,
dilated calyces or foci of parenchymal destruction.
49. CT SCAN
◼ Most useful.
◼ Large reniform mass with renal pelvis tightly surrounding a central calcification without pelvic dilatation
◼ Renal parenchyma is replaced by multiple water density masses representing dilated calyces &abscess
cavity .
◼ On enhancement the walls of the cavity demonstrate a prominent blush.
◼ Cavity fail to enhance whereas tumor enhance.
◼ CT is useful to know the extent of renal involvement &also adjacent organ or Fe abdominal wall.
50. RADIONUCLIDE RENAL SCANNING:
◼ 99mTC-DMSA is used
◼ confirm differential lack of function in the involved kidney
MRI:
◼ not yet super seeded to CT
◼ Advantage is in delineating extra-renal extension of inflammation
◼ T1 weighted image: appear as cystic foci of intermediate intensity signal
◼ T2 weighted image : hyper intensity signal
ARTERIOGRAPHY: shows hyper vascular areas.
◼ All radiological studies although distinctive often cannot differentiate between XGPN &Renal cell Ca
51. MANAGEMENT
◼ Primary obstacle to correct treatment is incorrect diagnosis.
◼ With CT scan preoperative diagnosis is 90%.
◼ Antimicrobial therapy
◼ To stabilise the patient preoperatively.
◼ Occasionally with initial stages long term.
◼ antimicrobial therapy will eradicate infection& restore renal function.
◼ Percutaneous drainage- non curative.
52. NEPHRECTOMY
◼ If diagnosed preoperatively for diffuse type nephrectomy is the treatment of choice
◼ For segmental involvement partial nephrectomy is considered
◼ LAPAROSCOPIC NEPHRECTOMY
◼ reasonable
◼ recent approach
53. RISK FACTORS AND COMPLICATIONS
▪ Bleeding.
▪ Infection.
▪ Injury to the kidney or other organs.
▪ Incomplete stone removal.
▪ Healing problems
54. PROGNOSIS
patients are usually able to return to normal activities within a few days to a week. However, it is
important to follow the post-operative instructions provided by the medical team, which may include
dietary changes, pain management, and follow-up imaging to ensure that all stones have been
removed.
It is also important to note that even after successful nephrolithotomy, there is a risk of developing
new kidney stones in the future. Therefore, it is recommended that patients make lifestyle changes
such as increasing water intake, maintaining a healthy weight, and avoiding high-salt and high-protein
diets to reduce the risk of recurrence.
