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Renal inflammatory disease

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UT Radiology Knoxville GU Lecture Series

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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

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