renal inflammatory disease
DESCRIPTION
UT Radiology Knoxville GU Lecture SeriesTRANSCRIPT
Renal Renal Infectious/InflamInfectious/Inflammatory Diseasematory Disease
Jud Gash, MDJud Gash, MD
OutlineOutline
PyelonephritisPyelonephritis Renal AbscessRenal Abscess Emphasematous PyelonephritisEmphasematous Pyelonephritis PyonephrosisPyonephrosis Xanthogranulomatous PyelonephritisXanthogranulomatous Pyelonephritis TBTB Renal MalakoplakiaRenal Malakoplakia Other InfectionOther Infection
PyelonephritisPyelonephritis PredispositionPredisposition
Most cases similar to lower UTI causes (esp Most cases similar to lower UTI causes (esp intercourse)intercourse)
About 20-30:1 cystitis to PNAbout 20-30:1 cystitis to PN Female, reflux, obstruction, stones, diabetes, Female, reflux, obstruction, stones, diabetes,
stasis (congenital anomalies, diverticula), stasis (congenital anomalies, diverticula), pregnancypregnancy
ClinicalClinical Gram negatives (E coli, Proteus, Pseudomonas, etc.)Gram negatives (E coli, Proteus, Pseudomonas, etc.) Flank pain and tenderness, fever, N/V, signs of Flank pain and tenderness, fever, N/V, signs of
cystitiscystitis
PyelonephritisPyelonephritis ImagingImaging
Usually not necessary (uncomplicated PN)Usually not necessary (uncomplicated PN) Reasons to image Reasons to image
Uncertain diagnosisUncertain diagnosis Severe symptomsSevere symptoms Atypical clinical situationAtypical clinical situation
men, unresolving, children, diabeticsmen, unresolving, children, diabetics Role out obstructionRole out obstruction Evaluate source in recurrent pyelonephritisEvaluate source in recurrent pyelonephritis
May see incidentallyMay see incidentally Note: imaging of PN/UTI in children whole Note: imaging of PN/UTI in children whole
separate topicseparate topic
PyelonephritisPyelonephritis PathophysiologyPathophysiology
Ascending Infection Ascending Infection Adhesions and Adhesions and
Endotoxins Endotoxins UreteropyelitisUreteropyelitis
Thickened, Thickened, enhancing enhancing UrotheliumUrothelium
Ureteral Ureteral ““ileusileus”” PyelonephritisPyelonephritis
Access/spread via Access/spread via papillapapilla
Wedge shaped and Wedge shaped and patchypatchy
Rarely Rarely hematogeneoushematogeneous
StaphStaph BilateralBilateral
UltrasoundUltrasound
RoleRole Detect ComplicationsDetect Complications
Pyonephrosis; abscessPyonephrosis; abscess Predisposing factorsPredisposing factors ScarringScarring
ImagingImaging Normal (75%?)Normal (75%?) EnlargementEnlargement Loss of corticomedullary Loss of corticomedullary
junctionjunction Decreased EchogenecityDecreased Echogenecity
Focal or diffuseFocal or diffuse Hyperechoic Hyperechoic
(hemorrhage)(hemorrhage) FocalFocal
Hypoechoic area on Hypoechoic area on Power DopplerPower Doppler
Severe unilateral acute bacterial pyelonephritis
Craig W D et al. Radiographics 2008;28:255-276
Craig W D et al. Radiographics 2008;28:255-276
PyelonephritisPyelonephritis
Radiographics. 2000;20:215-243 Craig W D et al. Radiographics 2008;28:255-276
PyelonephritisPyelonephritis CTCT
NoncontrastNoncontrast NormalNormal NephromegalyNephromegaly Perinephric strandingPerinephric stranding Loss of hyperdense pyramidsLoss of hyperdense pyramids Hyperdensities (hemorrhage)Hyperdensities (hemorrhage) Thickening of urotheliumThickening of urothelium Mild ureteral dilationMild ureteral dilation
ContrastContrast Wedges of hypoattenuation (edema, obstruction, and Wedges of hypoattenuation (edema, obstruction, and
vasospasm)vasospasm) Dense on delayedDense on delayed
Striations (focal, diffuse)Striations (focal, diffuse) May be abnormal for days or weeksMay be abnormal for days or weeks RoleRole
Diagnosis/alternative diagnosisDiagnosis/alternative diagnosis Acute complicationsAcute complications Underlying predispositions (CTU)Underlying predispositions (CTU)
ED – flank pain (no stone ED – flank pain (no stone seen)seen)
PyelonephritisPyelonephritis DDXDDX
PNPN Recent stone passageRecent stone passage Non-stone obstruction Non-stone obstruction
(clot, fungus ball, (clot, fungus ball, iodinovir)iodinovir)
Acute vascular lesion Acute vascular lesion (RA, RV occlusion)(RA, RV occlusion)
So, non-contrast So, non-contrast findings nonspecific. findings nonspecific.
Clinical exam/UA/hydro Clinical exam/UA/hydro should allow distinctionshould allow distinction
Consider contrast if Consider contrast if unclearunclear
RadioGraphics 2004;24:S11-S28
Craig W D et al. Radiographics 2008;28:255-276
Craig W D et al. Radiographics 2008;28:255-276
PyelonephritisPyelonephritis
RadioGraphics 2004;24:S11-S28
PyelonephritisPyelonephritis
Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
Acute bacterial pyelonephritis caused by hematologic seeding in a patient with Staphylococcus aureus
endocarditis
Craig W D et al. Radiographics 2008;28:255-276
Pyelonephritis – DDX (3 Pyelonephritis – DDX (3 II ’’s)s)
Radiographics. 2000;20:215-243
PyelonephritisPyelonephritis
Focal PyelonephritisFocal Pyelonephritis Replaces old terms Replaces old terms
(FLN, ABN, etc.)(FLN, ABN, etc.) May be pre-abscess May be pre-abscess
statestate Now focal or diffuse Now focal or diffuse
pyelonephritispyelonephritis ImagingImaging
Focal mass-like lesion Focal mass-like lesion can mimic tumorcan mimic tumor
Complications of Complications of PyelonephritisPyelonephritis
AcuteAcute AbscessAbscess
RenalRenal PerinephricPerinephric
Emphysematous PNEmphysematous PN PyonephrosisPyonephrosis
ChronicChronic Scarring/AtrophyScarring/Atrophy XGP/malakoplakiaXGP/malakoplakia Papillary NecrosisPapillary Necrosis
AbscessAbscess
EtiologyEtiology PN which proceeds to tissue necrosis PN which proceeds to tissue necrosis
and liquefactionand liquefaction More likely with obstruction, diabetes More likely with obstruction, diabetes
(75% of all abscesses), stone disease(75% of all abscesses), stone disease Normal kidneys or superinfect pre-Normal kidneys or superinfect pre-
existing lesions (cysts, diverticula, RCC)existing lesions (cysts, diverticula, RCC) Can spread to perinephric spaceCan spread to perinephric space
AbscessAbscess
ImagingImaging USUS
Rounded, thick wall Rounded, thick wall cystic mass with debriscystic mass with debris
CTCT Rounded cystic lesion Rounded cystic lesion
with enhancing wallwith enhancing wall Surrounding Surrounding
inflammatory changesinflammatory changes Microabscesses Microabscesses
Small, often multiple Small, often multiple areas in the setting of areas in the setting of PNPN
RadioGraphics 2004;24:S11-S28
Perinephric AbscessPerinephric Abscess
Usually Usually secondary to secondary to pyonephrosispyonephrosis Less commonly Less commonly
in in unobstructed unobstructed PNPN
Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
Emphysematous Emphysematous PyelonephritisPyelonephritis
Aggressive form of PN with necrosis, Aggressive form of PN with necrosis, vascular compromise and air productionvascular compromise and air production
Rare life threatening form urologic Rare life threatening form urologic emergencyemergency
90% diabetics 90% diabetics (poorly controlled)(poorly controlled) Obstruction common (must exclude)Obstruction common (must exclude) AdultsAdults
Rare, if ever, seen in pediatricsRare, if ever, seen in pediatrics Clinical presentationClinical presentation
Fever, flank pain, lethargy, renal failure, septic Fever, flank pain, lethargy, renal failure, septic shockshock
Usually gram negatives, esp. E. ColiUsually gram negatives, esp. E. Coli
Emphysematous Emphysematous PyelonephritisPyelonephritis
KUBKUB Gas collectionsGas collections Renal EnlargementRenal Enlargement Stones Stones
Radiographics. 2002;22:543-561
Emphysematous Emphysematous PyelonephritisPyelonephritis
Emphysematous Emphysematous PyelonephritisPyelonephritis
Emphysematous Emphysematous PyelonephritisPyelonephritis
Emphysematous Emphysematous PyelonephritisPyelonephritis
Radiographics. 2002;22:543-561
Emphysematous Emphysematous PyelonephritisPyelonephritis
USUS Hyperechoic dirty Hyperechoic dirty
shadowingshadowing DDX: DDX:
nephrocalcinosis nephrocalcinosis and and nephrolithiasisnephrolithiasis
Emphysematous Emphysematous PyelonephritisPyelonephritis
Radiographics. 2002;22:543-561
Emphysematous Emphysematous PyelonephritisPyelonephritis
CTCT Parenchymal air – Parenchymal air –
bubbles, linearbubbles, linear Severe inflammatory Severe inflammatory
changeschanges Look for obstructionLook for obstruction
Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
Emphysematous Emphysematous PyelonephritisPyelonephritis
TreatmentTreatment Nephrectomy – Nephrectomy –
traditional gold traditional gold standardstandard
If more limited, If more limited, milder form – milder form – percutaneous percutaneous drainage/relief drainage/relief of obstruction of obstruction and antibioticsand antibiotics
Radiographics. 2002;22:543-561
Emphysemtous pyelitisEmphysemtous pyelitis
Gas in collecting Gas in collecting systemsystem
Same Same epidemiology as epidemiology as EPNEPN
Better prognosis Better prognosis Relief of Relief of
obstruction/ABXobstruction/ABX
Emphysemtous pyelitisEmphysemtous pyelitis
Air In Collecting SystemAir In Collecting System Emphysematous Emphysematous
PyelitisPyelitis FistulaFistula IatrogenicIatrogenic
Radiology. 2001;218:647-650
PyonephrosisPyonephrosis
Obstructed, infected kidney Obstructed, infected kidney Cause of obstructionCause of obstruction
Stones (rarely other: Conj UPJ, tumor)Stones (rarely other: Conj UPJ, tumor) EmergencyEmergency
UrosepsisUrosepsis Renal destructionRenal destruction XGP (chronic)XGP (chronic)
TreatmentTreatment Drainage (perc neph/stent and Drainage (perc neph/stent and
antibiotics)antibiotics)
PyonephrosisPyonephrosis USUS
Large, hypoechoic kidneyLarge, hypoechoic kidney HydronephrosisHydronephrosis Echogenic debrisEchogenic debris Fluid – Fluid LevelFluid – Fluid Level
Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
Pyonephrosis – 4 casesPyonephrosis – 4 cases
PyonephrosisPyonephrosis CTCT
Findings of infectionFindings of infection Findings of obstructionFindings of obstruction Hypedense/debris in Hypedense/debris in
collecting system collecting system >30 hu (Note: 50%<15hu)>30 hu (Note: 50%<15hu)
Thick pelvic pelvic wall (2-Thick pelvic pelvic wall (2-5mm)5mm)
75% (Note: 10% of 75% (Note: 10% of uninfected obstruction)uninfected obstruction)
Emphysematous pyelitis Emphysematous pyelitis in 10%in 10%
Aspirate UrineAspirate Urine
Chronic PyelonephritisChronic Pyelonephritis
Controversial Controversial PathophysiologPathophysiologyy
FindingsFindings Renal ScarringRenal Scarring Calyceal Calyceal
ClubbingClubbing At Renal PolesAt Renal Poles
DDXDDX Renal infarctsRenal infarcts
Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis
(XGP)(XGP) Disorder immune response in Disorder immune response in
setting of chronic infection, setting of chronic infection, often with obstruction and often with obstruction and stones (ie pyonephrosis)stones (ie pyonephrosis)
PathophysiologyPathophysiology Stone leads to obstructionStone leads to obstruction Caliectasis (peripelvic fibrosis Caliectasis (peripelvic fibrosis
limits pelviectasis). limits pelviectasis). Infection leads to parenchymal Infection leads to parenchymal
destruction and replacement destruction and replacement with lipid laden macrophageswith lipid laden macrophages
TreatmentTreatment nephrectomynephrectomy
Radiographics. 2000;20:215-243
Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis
(XGP)(XGP) Key pointsKey points
Middle age women with longstanding Middle age women with longstanding infection/stonesinfection/stones DM in only 10%DM in only 10%
TriadTriad NonfunctionNonfunction Renal enlargement Renal enlargement
Caliectasis with less pelviectasis, parenchymal lossCaliectasis with less pelviectasis, parenchymal loss Stones (90%)Stones (90%)
Staghorn, explodedStaghorn, exploded
Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis
(XGP)(XGP) KUBKUB
““explodedexploded”” staghorn with staghorn with large renal large renal shadowshadow
USUS Caliectasis Caliectasis
(massive) with (massive) with debrisdebris
Stones Stones Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis
(XGP)(XGP) CTCT
““Bear ClawBear Claw”” Massive caliectasis Massive caliectasis
(without (without pelviectasis)pelviectasis)
Not fluid thoughNot fluid though Parenchyma Parenchyma
enhances (not enhances (not function)function)
StonesStones
Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
Xanthogranulomatous pyelonephritis
Craig W D et al. Radiographics 2008;28:255-276
©2008 by Radiological Society of North America
Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis
(XGP)(XGP)
Radiographics. 2000;20:215-243
Radiographics. 2000;20:215-243
Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis
(XGP)(XGP) Other FindingsOther Findings
Extrarenal Extrarenal ExtensionExtension
NodesNodes FistulaFistula SegmentalSegmental
TuberculosisTuberculosis PathophysiologyPathophysiology
Renal cortical Renal cortical deposition occurs deposition occurs in primary infectionin primary infection
Reactivation (one Reactivation (one kidney) in medullakidney) in medulla
Descending processDescending process Destruction, Destruction,
fibrosis, fibrosis, calcification, calcification, obstructionobstruction
DxDx Culture (sterile Culture (sterile
pyuria)pyuria)
TuberculosisTuberculosis
KUBKUB Diffuse or Diffuse or
scattered renal scattered renal calcifications calcifications (25%)(25%)
Often small Often small renal shadowrenal shadow
““putty kidneyputty kidney””
Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
TuberculosisTuberculosis CTU (IVP)CTU (IVP)
RenalRenal Moth eaten, fuzzy calyx with Moth eaten, fuzzy calyx with
papillary necrosispapillary necrosis Infundibular, pelvic fibrosis Infundibular, pelvic fibrosis
(purse string pelvis)(purse string pelvis) Calyceal/pelvic obstruction Calyceal/pelvic obstruction
(hydrocalyx, phantom calyx)(hydrocalyx, phantom calyx) Renal nonfunction Renal nonfunction
(autonephrectomy), scarring (autonephrectomy), scarring calcification (putty kidney)calcification (putty kidney)
Note: renal changes mimic Note: renal changes mimic TCCTCC
UreterUreter Ulcerations and irregularity; Ulcerations and irregularity;
sawtooth (early)sawtooth (early) Multiple strictures; corkscrew Multiple strictures; corkscrew
(later)(later) Short, strait, aperistaltic Short, strait, aperistaltic
(latest)(latest) Calcifications (DDX: Calcifications (DDX:
schistosomiasis)schistosomiasis) Bladder involvement is very Bladder involvement is very
latelate
AJR 2005; 184:143-150
Renal Parenchyma Renal Parenchyma MalakoplakiaMalakoplakia
(RPM)(RPM) Inflammatory condition to chronic E. coli Inflammatory condition to chronic E. coli
infectioninfection Disordered macrophage response to bacterial Disordered macrophage response to bacterial
phagocytosisphagocytosis histologic hallmark is basophilic inclusions histologic hallmark is basophilic inclusions
(Michaelis-Gutmann bodies) within large (Michaelis-Gutmann bodies) within large eosinophilic macrophages (von Hansemann eosinophilic macrophages (von Hansemann histiocytes) histiocytes)
Entire GU tract can be affectedEntire GU tract can be affected Most commonly urothelial plaques (bladder esp.)Most commonly urothelial plaques (bladder esp.) RPM occurs uncommonlyRPM occurs uncommonly
Usually middle age women with h/o chronic Usually middle age women with h/o chronic infectioninfection Flank pain, feverFlank pain, fever
Renal Parenchyma Renal Parenchyma MalakoplakiaMalakoplakia
(RPM)(RPM) Findings:Findings:
Bilateralor Bilateralor unilateralunilateral
Focal, multifocal Focal, multifocal or diffuseor diffuse
infiltrating infiltrating massesmasses
Renal pelvis Renal pelvis involvement may involvement may occuroccur
Calcifications Calcifications uncommonuncommon
Radiographics. 2000;20:215-243.)
Fungal DiseaseFungal Disease Usually Usually
immunocompromised immunocompromised (DM, steroids, HIV, etc.)(DM, steroids, HIV, etc.)
Candida most commonCandida most common Any portion of urinary Any portion of urinary
tracttract ImagingImaging
Changes of PN, abscessChanges of PN, abscess Fungus ball in collecting Fungus ball in collecting
systemsystem Non-stone (echogenic) Non-stone (echogenic)
filling defectfilling defect DDX: sloughed papilla, DDX: sloughed papilla,
tcc, clottcc, clot
Kawashima A - Infect Dis Clin North Am - 01-JUN-2003
OutlineOutline
PyelonephritisPyelonephritis Renal AbscessRenal Abscess Emphasematous PyelonephritisEmphasematous Pyelonephritis PyonephrosisPyonephrosis Xanthogranulomatous PyelonephritisXanthogranulomatous Pyelonephritis TBTB Renal MalakoplakiaRenal Malakoplakia Other InfectionOther Infection