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Non tubercular infections of GUT- Dr Niranjan Patil.pptx
- 1. NON TUBERCULAR INFECTIONS OF THE URINARY TRACT DR N CHIRAG
- 2. BACTERIAL INFECTIONS Women have a much higher incidence of lower urinary tract infection because of the short length of the female urethra. In patients younger than 50 years, bacterial infections of the kidney are much more common in women than in men. Beyond this age, however, the incidence of urinary tract infection in men increases, as a result of urinary stasis caused by benign prostatic hypertrophy. present with fever, flank pain, chills, and other systemic symptoms such as nausea, vomiting, and malaise upper urinary tract infection and help to differentiate them from those infections involving only the lower urinary tract. Conditions that predispose patients with lower urinary tract infection to renal involvement include vesicoureteral reflux. urinary tract obstruction, calculi, altered bladder function, altered host resistance, pregnancy, and congenital urinary tract anomalies.
- 3. Immunocompromised patients and those with underlying diabetes mellitus are of particular concern because they are more vulnerable to the development of complications from acute pyelonephritis. It is also more difficult to establish the diagnosis on clinical ground & in patients with diabetes as many as 50% of these patients will not present with the typical flank tenderness that helps differentiate pyelonephritis from lower urinary tract infection. Hence, a more aggressive approach to imaging in patients with diabetes is indicated. Gram-negative enteric pathogens, including B. coli, Proteus mirabilis, Pseudomonas aeruginosa, and Klebsiella spp., are responsible for the vast majority of bacterial renal infections. Acute pyelonephritis is an acute bacterial infection of the kidney manifested by infiltration of the renal interstitium with neutrophils. The kidney is swollen; the tissues are hyperemic; and small micro abscesses. 1 to 5 mm. in diameter, may be present. The process may be unilateral or bilateral and focal or widespread; its distribution is usually focal. so that involved areas are interspersed with zones of unaffected renal tissue .
- 4. ACUTE PYELONEPHRITIS The rationale for performing an imaging study is not to diagnose acute pyelonephritis. but to look for an underlying anatomic: abnormality that may have predisposed the patient to the infection, to search for a calculus or an obstruction that may prevent a rapid therapeutic response, or to diagnose a complication of the infection such as a renal or perinephric abscess. Contrast-enhanced computed tomography (CT) or CT urography (CTU) is the imaging study of choice for the diagnosis of atypical pyelonephritis or to look for a potential complication of the infection such as a renal or perinephric abscess, or renal emphysema. Ultrasound is less sensitive than CT in revealing foci of inflamed renal parenchyma. Acute uncomplicated pyelonephritis is the most common bacterial infection involving the kidney. The infection usually responds quickly (within 48 to 72 hours) to antibiotic therapy and generally does not lead to permanent morphologic damage.
- 5. Excretory urography is usually normal. but findings may include: 1. Diffuse renal enlargement, reflecting the edema that accompanies the infection. 2. Delay in the appearance, and diminution of concentration of the contrast medium in the renal collecting system 3. Attenuation of the intrarenal collecting system, as the result of diminished excretion and parenchymal edema; 4. Decrease in the density of the nephrogram in the affected portion of the kidney.
- 11. ACUTE RENAL ABSCESS Most renal abscesses form as a result of the coalescence of small micro abscesses that are present in acute pyelonephritis. The predominant organisms responsible for abscesses are gram-negative enteric species that occur in the setting of diabetes mellitus, drug abuse,vesicoureteral reflux or renal calculus disease. Acute abscesses may be solitary or may form simultaneously in multiple locations in the kidney. Multiple lesions are less common and suggest hematogenous dissemination. Fever, leukocytosis, pyuria. and flank pain are common.
- 15. PERINEPHRIC ABSCESS A primary perinephric abscess forms when an intrarenal abscess breaks through the renal capsule into the perinephric space or as a result of obstruction with extravasation of infected urine. Secondary perinephric abscesses may form when infection is spread to the perinephric space hematogenously from an external source. A perinephric abscess may form from acute inflammation of an adjacent organ or from perforation of adjacent gut, that is, ruptured appendix or diverticulitis. In most cases. symptoms of urinary infection have been present for periods longer than 2 weeks. Fever is usually intermittent and low grade. As many as 25% of patients have normal urinalysis. The development of a perinephric abscess as a complication of renal inflammatory disease is more common in patients with large staghorn calculi, pyonephrosis, diabetes mellitus. or a neurogenic bladder. On radiographs, large perinephric abscesses may be identified as soft-tissue masses in the perinephric space. The psoas margin may be obscured. Air secondary to gas-forming organisms is found in a number of large perinephric abscesses. On ultrasonography, perinephric abscesses appear as masses of variable echogenicity adjacent to the kidney. Gas within the abscess will demonstrate acoustic shadowing, but when the abscess is anterior to the kidney, gas may be confused with intestinal gas
- 18. PYONEPHROSIS pyonephrosis refers to a pus-filled obstructed renal c:ollecting system. The clinical seriousness of the condition varies, but when severe, it constitutes a true urologic emergency; if untreated, it may lead to sepsis and death. Most patients with pyonephrosis have clinical evidence of urinary tract infection. Calculi are the cause of the associated urinary tract obstruction in a majority of cases; metastatic disease, postoperative ureteral strictures. and processes such as retroperitoneal fibrosis account for the remainder. Plain abdominal radiographs demonstrate obvious urinary tract calculi in approximately one half of the patients.
- 20. GAS FORMING RENAL INFECTIONS Emphysematous pyelonephritis is an unusual, often severe, variant of upper urinary tract infection in which gas formed by the infecting bacteria appears in the renal parenchyma, adjacent tissues, or collecting system. Patients usually have poorly controlled diabetes and hyperglycemia and may have ureteral obstruction, so that emphysematous pyelonephritis is a complication of pyonephrosis. Patients are usually severely and acutely ill. and may have shock and uremia; women are more often affected than men. The pathogen is usually a gram-negative bacterium; E. coli is most common, followed by klebsiella, Aerobacter, and Proteus. The gas may be demonstrated by radiography, CT, or ultrasound since CT can best delineate the anatomic distribution of the gas, the other signs of infection, and the site and etiology of any ureteral obstruction, it is the best modality for this condition.
- 23. The classic: therapy has involved urgent nephrectomy; it was felt that surgery was necessary to prevent a very high mortality from the disease. More recently, it has become apparent that many patients can be treated with antibiotics and drainage of any dosed pus-containing cavity. For cases with ureteral obstruction, percutaneous nephrostomy should be performed (although some urologists will prefer to place ureteral stents), and any abscess should be drained percutaneously. This regimen permits many affected patients to have their infection successfully treated. to retain their kidneys, and to regain renal function.
- 24. RENAL FISTULA In addition to the emphysematous infections described above, surgery and intubation may introduce air, as may trauma and fistulae to the intestinal tract. Reno-alimentary fistulae are rare. They may result from Crohn disease, from tumors in the kidney or the gastrointestinal tract. or from severe renal trauma. Most commonly,however, renal fistulae occur as a result of renal inflammatory disease. Usually, fistulae develop between the kidney and the colon , but the duodenum, stomach, and distal small bowel may also be involved. Renal fistulae occur in the setting of renal or perinephric abscesses or pyonephrosis, often complicated by calculi. In the older literature, renal tuberculosis was described as the causative factor in 25% of the cases; it may still be a relatively common factor in undeveloped parts of the world.
- 26. XANTHOGRANULOMATOUS PYELONEPHRITIS Xanthogranulomatous pyelonephritis (XGP) is a relatively uncommon form of renal inflammatory disease characterized histologically by the presence of lipid-laden macrophages (xanthoma cells), as well as by other inflammatory cells including plasma cells, leukocytes, and histiocytes. signs and symptoms of the disease are nonspecific and usually long-standing; fever, malaise, flank pain or tenderness, weight loss, and leukocytosis are the most common presenting complaints. Lower urinary tract symptoms (frequency, dysuria) are present in only one half of patients. Anemia is present in 70% of patients; approximately 25% of patients demonstrate abnormalities in liver function tests; and about 10% of patients have underlying diabetes mellitus. Although most patients range from 45 to 65 years of age, patients as young as 5 years of age have been reported.
- 27. Active urinary tract infection with E. coli. P. mirabilis, Klebsiella, or P. aeruginosa alone or in combination is present in virtually every case. XGP probably represents an uncommon reaction by the kidney to a long-standing purulent infection. This is most commonly chronic obstructive pyonephrosis. which may be due to a calculus (75%), but less commonly may be secondary to a congenital ureteropelvic junction obstruction or a ureteral tumor. It may also be seen in patients with long-standing renal abscesses. The classically described triad of findings includes: (1) staghorn calculus. (2) absent or diminished excretion of contrast medium, and (3) a poorly defined renal mass. Sonography usually demonstrates diffuse renal enlargement with a central echogenic focus representing the staghorn calculus.
- 30. Replacement Lipomatosis XGP must not be confused with replacement lipomatosis, which is an advanced form of sinus lipomatosis. As with XGP, replacement lipomatosis is associated with renal stones and inflammatory changes in the majority of cases. There is atrophy of the renal parenchyma, and there may be abscess formation. However, rather than hydronephrosis, there il a marked proliferation of renal sinus fat.
- 31. Malacoplakia Malacoplakia is an uncommon form of granulomatous renal inflammatory disease characterized histologically by distinctive histiocytes (von Hansemann cells) that contain basophilic staining inclusions called Michaelis-Gutmann bodies. These inclusions are thought to represent phagocytized fragments of bacteria. It has been postulated that malacoplakia represents an enzymatic defect within the histiocytes such that intracellular digestion of the phagocytized bacteria. is incomplete. Malacoplakia may occur throughout the urinary tract, Malacoplakia occurs in women four times aa frequently as in men, Patients may be of any age, but the peak incidence is among patients older than 50 years. Fever, flank pain, and a palpable flank. mass are the most common presenting complaints. Most patients have active urinary tract infection, and B. coli is the organism found in 90% of patients. Patients often have a history of altered holt resistance, including autoimmune disease, alcoholism, carcinoma, or rheumatoid arthritis. Two forms of RPM have been described. Multifocal involvement occurs in 75% of patients and is reported to be bilateral in one half of these patients. The kidney is enlarged and contains multiple yellow-brown masses that range in size from a few millimeters to a few centimetres.
- 32. Unifocal RPM presents as a solitary mass ranging in size from 2 to 8 cm that is sharply demarcated from the remainder of the kidney. With bilateral disease, renal failure is common. Major organ involvement is reported to have a 50% mortality. Nephrectomy is the usual treatment for unilateral disease. radiologic findings depend on the pattern of involvement. With multifocal RPM, diffuse enlargement of the kidney is found frequently. Excretion of contrast medium is diminished in more than one half of the cues, presumably secondary to extensive renal parenchymal replacement Sonography may demonstrate multiple ill-defined masses of varying echogenicity. CT demonstrates multiple soft-tissue masses within the kidney that enhance less than normal renal parenchyma. On MRI, the affected regions demonstrate low signal intensity on both Tl- and Tl-weighted images and enhance poorly. Extension of the inflammatory process into the retroperitoneum may also be demonstrated. angiography demonstrates stretching of intrarenal branch vessels with an inhomogeneous angiographic nephrogram .
- 35. Chronic Pyelonephritis The term chronic atrophic pyelonephritis applies to a particular type of renal parenchymal scarring in which the cortex and medulla are focally thinned and the underlying c:alyces are blunted. have a number of causes, including vesicoureteral reflux, calyceal stones, or severe focal pyelonephritis. Intrarenal reflux of infected urine causes an acute inflammatory reaction in the renal parenchyma that overlies that papilla. This ultimately results in parenchymal scarring, which extends throughout the thickness of the renal cortex and causes retraction of the overlying calyx. The radiologic findings of chronic pyelonephritis on CT, CTU, and MRI include the demonstration of one or more parenchymal scars typically in the upper pole of the kidney overlying a deformed calyx. ultrasound changes in patients with chronic atrophic pyelonephritis include a focal loss of parenchyma, which can be appreciated on longitudinal or cross-sectional image. Increased echogenicity in the area of the scar may also be demonstrated.
- 37. Fungal Infections Fungal diseases of the kidney develop as opportunistic infections occurring principally in the setting of altered host resistance from Such diverse entities as diabetes mellitus, the use of systemic antibiotics, the use of immunosuppressive and chemotherapeutic agents, the use of indwelling intravenous or urinary catheters, acquired immunodeficiency, and renal transplantation. Renal involvement most commonly occurs with infections secondary to Candida albicans or other Candida spp, but has been reported in association with Coccidiomycosis immitis, Cryptococcus neoformans, Torulopsis-glabrata, and Aspergillus fumigatus. Fungal infections may also complicate conventional gram-negative urinary tract infections. Renal candidiasis is not common, and usually occurs in infants or patients with immune compromise. The disease produces parenchymal inflammation and multiple abscess; inflammation of the deep medulla may cause papillary necrosis. Hyphae may proliferate in the collecting systems and form fungus balls. which in tum may obstruct urine outflow and destroy renal function.
- 42. Leukoplakia (Squamous Metaplasia) Squamous metaplasia is a rare inflammatory condition, usually associated with chronic infection and/or stone disease, which may occur in the collecting system, ureter, or bladder. When found in the ureter, involvement is usually of the proximal third and is almost always associated with involvement of the renal pelvis. The condition is bilateral in 10% of cases. The term leukoplakia refers to a white patch seen on the surface of an area of squamous metaplasia when the keratinized epithelium forms a soft-tissue mass, the condition is referred to as a cholesteatoma. the malignant potential of the lesion in the renal collecting system probably is low Imaging typically reveals the lesion as a flat mass or region of thickening of the renal pelvic or ureteral wall; the thickening may give a corduroy appearance
- 44. Pyelitis and Ureteritis cystica This condition consists of multiple, small, subepithelial fluid-filled cysts in the wall of the renal pelvis and/or ureter. They are thought to be caused by degeneration of the basal layer of the urothelium, which results in proliferation of the surface epithelial cells; these become isolated from the epithelial surface and form fluid-filled cysts that project into the lumen of the ureter. This degeneration occurs with chronic urinary tract infection. which may or may not be present at the time of diagnosis. Pyelitis and ureteritis cystica are usually asymptomatic but may be accompanied by hematuria and symptoms of urinary tract infection. They do not cause obstruction and are not premalignant. They may be unilateral or bilateral and appear slightly more frequently in women. Although these conditions have been reported in all age groups, they are typically found in patients between 50 and 60 years of age.
- 46. Pseudodiverticulosis Ureteral pseudo diverticulosis consists of one or more small ( 4-mm or less) out pouchings of the ureter. The lesions are hyperplastic buds of ureteral epithelium that project from the ureteral lumen into, but not entirely through, the muscular layers of the ureteral wall. Thus, they are not true diverticula. Ureteral pseudo diverticulosis may be associated with hematuria and urinary tract infection; it has also been found to coexist with a wide range of urinary tract conditions, including calculi, benign prostatic hypertrophy, and TCC.
- 47. Acute Bacterial Cystitis Acute cystitis is present when more than 100,000 bacteria are present in 1 mL of urine. Most bacteria causing cystitis enter the bladder through the urethra. Escherichia coli is the most commonly encountered organism, but other common agents include species of Staphylococcus, Streptococcus, Proteus. Pseudomonas, Aerobacter, and candida. Infection is more common when the bladder mucosa has been damaged by trauma, stone, or tumor; when outlet obstruction prevents bacteria from being completely washed out; and when bladder catheterization or instrumentation introduces infection by bypassing the protective mechanisms of the urethra and prostate. cystitis may recur two or three times in a sexually active women, more frequent recurrence of acute cystitis and cases that are resistant to antibiotic therapy suggest an underlying cause. In such cases. imaging of the entire urinary tract and cystoscopic evaluation of the bladder are indicated to exclude causes such as urinary stone disease,bladder diverticulum, colovesical fistula, and perivesical abscess.
- 48. Emphysematous Cystitis Emphysematous cystitis is a rare condition nearly always found in diabetic or immunocompromised patients. This is a true infectious cystitis most often due to E. coli, which ferments glucose to produce carbon dioxide and hydrogen. This gas is initially formed in the bladder wall and subsequently transgresses the mucosa into the lumen of the bladder.
- 49. Schistosomiasis Schistosomiasis (Bilharzia) is one of the most common parasitic infections in the world, but is especially prevalent in the Nile Valley. The clinical presentation of patients with schistosomiasis is typically haematuria. ln initial stages, the bladder mucosa is edematous and hemorrhagic. Later, the bladder becomes fibrotic with a reduced volume and calcified wall. Cystoscopic examination is mandatory to exclude squamous cell carcinoma of the bladder, which bas a markedly increased incidence in patients with schistosomiasis.
Editor's Notes
- In general, the degree of radiographic abnormality and the degree of impairment of contrast excretion reflect the severity of the interstitial inflammatory disease Noncontrast CT demonstrate. diffuse parenchymal swelling without a focal parenchymal defect. B: Post contrast CT shows striated nephrographic defects typical of acute pyelonephritis.
- utrasound in patients with acute uncomplicated pyelonephritis may be normal or shows diffuse or focal renal enlargement with regions of increased or decreased echogenicity of the renal parenchyma. The normal cortio medullary differentiation may be lost. B: Corresponding power Doppler image shows decreased perfusion in the affected area.
- Unenhanced scans may be normal or show only renal enlargement; there may be perinephric stranding, which reflects inflammation or edema. After intravenous contrast administration , areas of decreased contrast enhancement appear. These regions may be in homogeneous or striated and wedge-shaped or rounded, and may almost always extend to the renal capsule.
- if delayed scans are obtained, the abnormal areas may reveal a dense nephrogram. which persists after the normal parenchyma has lost its enhancement. Differential diagnosis of regions of diminished or inhomogeneous enhancement may include acute ischemia or contusion; if there is focal swelling, the lesion may resemble an infiltrating tumor. Clinical data often permit a specific diagnosis. and ischemia may be accompanied by the peripheral rim sign or visible vascular abnormalities.
- Atypical appearance produced by treated pyelonephritis. ct shows a rounded area of decreased enhancement in the right kidney without significant mass effect; this is in contrast to the striated areas more typical of untreated acute pyelonephritis. Radionuclide imaging in patients with acute pyelonephritis has been reported using renal cortical imaging agents, such as 99mTc-DMSA, and agents. such as gallium 67(67Ga) citrate, which image areas of inflammation. Renal cortical imaging studies may show an inhomogeneous distribution of the radionuclide within the affected kidney or polar defects with asymmetric tracer uptake. a pattern that was specific for the diagnosis of pyelonephritis. termed the flare pattern, representing a striate distribution of decreased radioactivity was present.
- On sonography. abscesses appear as relatively sonolucent lesions with differing amounts of solid tissue echoes; the pus may contain low amplitude Echoes. a) The cursor indicate the margins of the abscess, which has a septum and a small amount of dependent debris. b) Airows indicate the abscess; multiple soft-tissue echoes suggest that it is evolving from a phlegmon. Doppler studies show no flow in the necrotic pus-filled region.
- CT is the imaging study of choice for the diagnosis of an acute renal abscess. Acute renal abscess. An un ecnhanced Ct scan demonstrate an acute multioculated renal abscess The lesion is a low-attenuation (10 to 20 HU) rounded or ovoid mass that does not enhance with contrast administration. & a result of the surrounding inflammatory process, the borders of the mass are usually indistinct; the degree of enhancement of the abscess wall is variable. The presence of gas within the abcess is virtually pathognomonic of an abscess. There is uaually thickening of Gerota fascia. and increased density may be found in the adjac;ent perinephric and mesenteric fat. The abscess may or may not extend into the perinephric space.
- A-T2-weighted image.inwhic:h the pus appear bright B-Tl-weighted image with gadolinium; the pus is hypointense. and the inflammatory ring is prominently enhanced.
- When fibroblasts migrate into the area of an acute renal abscess and form a barrier between the abscess and the remainder of the kidney, a chronic renal abscess is formed. chronic renal abscess is seen as a fluid filled mass. Although the interior of the mass is avascular, there is frequently a prominent enhancing rim seen on CT. Although this rim is characteristic of a chronic renal abscess, it may also be found in some necrotic or cystic renal neoplasms.
- The imaging study of choice for the detection of perinephric Abscess is ct. B-A chronic renal abscess containing an extruded calculus is present in the inferior portion of the kidney. A perinephric component with an enhancing rim is seen. A-Left perinephric abscess. An enhanced ct examination reveals a large left posterior perinephric abscess with involvement of the abdominal wall and paraspinal muscles. C-Perirenal and renal abscess; Tl-weighted gadolinium: enhanced MRI. The pus is hypointense, and the inflammed rims of tissue enhance intensely.
- Percutaneous drainage of renal and perinephric abscess using radiologic guidance is the preferred method of therapy if the lesion is large; small renal abscesses may be successfully treated by intravenous antibiotics alone. Percutaneous drainage provides satisfactory clinical results using only local anesthesia and obviates the need for open surgical drainage. Fluoroscopic, ultrasonic. or ct guidance may be used. ct shows an intrarenal, oval shaped abscess. With the patient in the prone position, CT-guided aspiration is performed .
- Longitudinal ultrasound image shows a dilated renal collecting system with multiple, low-level echoes within the collecting system. Sonography may differentiate pyonephrosis from sterile hydronephrosis by demonstrating echo" in the collecting system lumen, which may either be diffuse or appear as dependent layers of debris, or by shadowing echogenic gas bubbles within the pus in case of emphysematous infection.
- A grossly dilated collecting system with some contrast medium excretion and an air-fluid level is present. grossly hydronephrotic left kidney secondary to a staghorn calculus obstructing the renal pelvis. Although rare, layering of contrast medium above purulent material in the collecting system allows a specific diagnosis of pyonephrosis. Percutaneous aspiration of infected urine using radiologic guidance is the definitive diagnostic study in suspected pyonephrosis. Treatment requires drainage by nephrostomy or ureteral stenting along with antibiotics. If percutaneous nephrostomy is performed. care should be taken not to distend the collecting system by injecting contrast because patients may develop serious complications from the procedure including frank sepsis and septic shock.
- Coned view of the right kidney showing a bubbled appearance within the renal parenchyma secondary to diffuse infiltration of the kidney by gas. An air pyelogram and ureterogram are also present. The gas may appear with a great variety of amount and distribution. It may be present within the collecting system, where it is termed emphysematous pyelitis and is usually an indication of less severe disease . CT reveales air in an upper pole calyx.
- Severe emphysematous pyelonephritis in a transplanted kidney. There is air throughout the parenchyma. Bilateral emphysematous pyelonephritis. There is air in calyces bilaterally and in the left renal pelvis.
- Initial CT demonstrates a large hydronephrotic left kidney that displaces and compresses the left colon . Thickening of Gerota fascia is also present. Repeat CT, before any surgical intervention. Demonstrates decompression of the hydronephrosis with air in the collecting system as a result of fistulization to the left colon.
- Plain radiograph demon.rtrates bilateral stag· horn calculi. B: CT demonstrates gross hydronephrosis with extension of the inflammatory process to the perinephric space C: Retrograde pyelogram demonstrates filling defects in the renal pelvis and calyces from the calculi and gross papillary necrosis secondary to infection.
- Two forms of XGP have been described. The most common form(85%) results in diffuse involvement of the affected kidney. In the localized form of XGP (15%), the inflammatory process is limited to a portion of the kidney. This form is sometimes referred to as the "tumefactive form of XGP because the finding are more easily confused with a renal tumor . The majority of cases of both forms of XGP demonstrate extensive perinephric Inflammation Noncontrast CT shows a mass that contains punctate calcification projecting from the anterior margin of the kidney. B: After contrast, inhomogeneous enhancement is present. The findings cannot be distinguished from those of a localized renal cell carcinoma.
- A marked proliferation of renal sinus fat is demonstrated on this with unenhanced ct.
- A: CT scan shows a large, inhomogeneous, poorly marginated mass arising from the posterior aspect of the left kidney. There is extension into the perinephric space and left flank. B: Nephrogram phase from a selective renal angiogram shows a diffusely inhomogeneous nephrogram connsistent with the multifocal form of involvement.
- Malacoplakia may also affect the renal c:ollecting systems and ureters, forming multiple thick plaques that may be demonstrated with pyeloureterography . If ureteral lumina are compromised, renal failure may ensue. Ureteral malacoplakia . Retrograde ureterography shows multiple thick mural plaques in each case.
- An enhanced CT examination reveals marked parenchymal loss aasociated with a blunted calyx.
- Ultrasound typically shoW5 renal enlargement, a general increase and inhomogeneity of parenchymal echogenicity and focal regions of diminished echoes where abscesses have formed. Mycetomas are echogenic but nonshadowing, and may form discrete fungus balls. CT also shows the affected kidneys to be enlarged and to have diminished and inhomogeneous parenchymal nephrograms; discrete abscesses may appear as poorly marginated fluid-filled regions. Extensive bilateral renal and splenic candidiasis. The affected organs enhance in homogeneously; the small lucent portions represent innumerable abscesses.
- Pyelography may demonstrate hydronephrosis; fungus balls present as lucent-filling defects occasionally. cystography may reveal fungus balls in the bladder. Retrograde pyelography shows collecting system mycetoma that appears as a lucent filling defect occupying nearly the entire collecting system. Scalloping of the ureters related to submucosal edema, analogous to the changes in the esophagus produced by oral thrush, bas also been reported.
- The fungus may produce renal parenchymal inflammation with large or small abscesses , papillary necrosis, and fungus balls. Renal abscess due to aspergillosis. There is no prominent enhancing ring, but the diminished nephrogram in the left kidney reveals that the organ it diffusely involved.
- HIV infection results in an increased susceptibility to both opportunistic and pyogenic renal infections as a result of depletion of T-helper lymphocytes. Among the opportunistic infections, P. carinii, although usually thought of primarily as a pulmonary disease, is becoming more common in extrapulmonary sites because of the widespread use of pentamidine inhalers for prophylaxis The disease may spread by hematogenous and lymphogenous dissemination to a variety of organs, including the kidneys. Punctate renal calcifications are characteristic of renal involvement, but have been reported in Mycobacterium avium-intracellulare (MAI) and cytomegalovirus infection as well. Pneumoty carinii infection. A: Longitudinal ultrasound of the right kidney shows multiple focal areas of increased echogenieity. B: The presence of punctate bilateral renal calcification is confirmed by CT.
- The typical radiographic appearance is that of multiple, small (2- to 3-mm) radiolucent filling defects in the renal pelvis or ureter. In the ureter, they have a slight predilectionfor the proximal third and cause scalloping or even a ragged appearance of the ureteral margins when seen in profile duringurography or retrograde pyelography. Multiple, small. well-defined lesions are demonstrated on this retrograde pyelogram. Many lesions can be seen arising from the ureteral wall.
- The small diverticula are well demonstrated; notice the minimal ureteral narrowing at the site of the larger diverticula. The proximal and middle third of the ureter are more frequently affected than the distal third. The condition does not cause ureteral obstruction.
- In patients with emphysematous cystitis, the plain film typically shows gas within the bladder and irregular streaky radiolucencies within the bladder wall. Linear collections of gas within the bladder wall (arrows) indicate infection in this patient with diabetes mellitus. Contrast-enhanced axial CT image shows characteristic air in the bladder Will, the bladder lumen, and in a right lower quadrant renal transplant collecting system.
- Plain-film radiograph of the pelvis showing marked bladder wall calcification. Seminal vesicle calcification is also seen through the bladder outline. Plain-film radiograph of the pelvis reveals a faintly calcified wall in a somewhat contracted bladder in a patient with schistosomiasis. Note that the right inferolateral. wall of the bladder is not calcified . This loss of calcification in a previously calcified bladder is indicative of the development of a tumor in this region.