Department of Emergency Medicine and Public Health, University of Washington, 1126 18
Department of Emergency Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104-2499, USAUnited States
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A 30-year-old female with multiple presentations for pyelonephritis was diagnosed with Xanthogranulomatous pyelonephritis (XGP) by computed tomography (CT) scan. This patient was intermittently symptomatic for 8-years with numerous healthcare encounters without the correct diagnosis. The patient was treated recurrently for pyelonephritis with transient clearing of her symptoms without diagnostic imaging. The prolonged nature of her disease likely resulted in a complicated surgical course with inflammation of her liver and inferior vena cava. XGP is an uncommon disease characterized by chronic infection and inflammatory process resulting in the destruction of the kidney. The disease affects both adults and children, has a female pre dominance and is usually unilateral. An obstructive process and bacterial infection are contributing factors. The disease can be complicated by locally invasive and seeding infection, abscess development and systemic disease. Treatment consists of temporization with antibiotics and nephrectomy.
Keywords: Emergency medicine; Nephrology; Xanthogranulomatous
Case Report Staghorn Calculus and * *Corresponding author Xanthogranulomatous Pyelonephritis Stephen C. Morris, MD, MPH Assistant Professor Department of Emergency Medicine Complicated by Inflammation of the and Public Health University of Washington Vena Cava th 1126 18 Ave East Seattle, WA 98195, USA Tel. 6179559956 1* 2 Stephen C. Morris, MD, MPH ; Elizabeth Dorn, MD, DTMH Fax: 6179559956 E-mail: stephenmorrismd@gmail.com 1 th 1Department of Emergency Medicine and Public Health, University of Washington, 1126 18th Ave East, Seattle, WA 98195, USA Volume 3 : Issue 2 Article Ref. #: 1000EMOJ3145 2Department of Emergency Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104-2499, USA Article History th Received: November 15th, 2017 ABSTRACT th Accepted: December 20th, 2017 th Published: December 20th, 2017 A 30-year-old female with multiple presentations for pyelonephritis was diagnosed with Xan- thogranulomatous pyelonephritis (XGP) by computed tomography (CT) scan. This patient was intermittently symptomatic for 8-years with numerous healthcare encounters without the cor- Citation rect diagnosis. The patient was treated recurrently for pyelonephritis with transient clearing of Morris SC, Dorn E. Staghorn calcu- lus and xanthogranulomatous py- her symptoms without diagnostic imaging. The prolonged nature of her disease likely resulted elonephritis complicated by inflam- in a complicated surgical course with inflammation of her liver and inferior vena cava. XGP is mation of the vena cava. Emerg an uncommon disease characterized by chronic infection and inflammatory process resulting Med Open J. 2017; 3(2): 66-68.
in the destruction of the kidney. The disease affects both adults and children, has a female pre- doi: 10.17140/EMOJ-3-145 dominance and is usually unilateral. An obstructive process and bacterial infection are contrib- uting factors. The disease can be complicated by locally invasive and seeding infection, abscess development and systemic disease. Treatment consists of temporization with antibiotics and nephrectomy.
KEY WORDS: Emergency medicine; Nephrology; Xanthogranulomatous.
ABBREVIATIONS: XGP: Xanthogranulomatous pyelonephritis; CT: Computed Tomography; CVA: Costovertebral Angle.
CASE STUDY A 30-year-old female who presented twice to the emergency department separated by 2-weeks with complaints of right flank and suprapubic abdominal pain, dysuria, fevers, nausea, and vomiting. In the initial emergency department encounters she was diagnosed with a urinary tract infection and presumed pyelonephritis and started treatment with ciprofloxacin. She had a resolution of her symptoms over the course of 10 days of treatment; however, upon completing the course of her antibiotics her symptoms reoccurred. Her past medical history is notable for a kidney stone diagnosed 8-years ago at the time of pregnancy. She subsequently endorses ap- proximately 3 urinary tract infections yearly, some with right flank pain, that have been treated with outpatient antibiotics. She reports that her current symptoms are similar to those events, however, her pain is more severe. She denies any family history of kidney stones, and her only Copyright other past medical history is mild asthma.
©2017 Morris SC. This is an open access article distributed under the Creative Commons Attribution 4.0 Upon arrival to the emergency department on her second visit she was found to be International License (CC BY 4.0), afebrile and tachycardia at 127-bpm with a normal blood pressure in moderate discomfort. which permits unrestricted use, distribution, and reproduction in Physical examination demonstrated suprapubic and severe right-sided costovertebral any medium, provided the original work is properly cited. angle (CVA) tenderness to palpation.
While universal guidelines for management of recur- sulted in nephrectomy complicated by inflammation of the liver rent urinary tract infections and pyelonephritis are not compre- and vena cava. Other known complications of XGP such as in- hensive the use of imaging by computed tomography (CT) scan ferior vena cava thrombus, septic emboli, abscess, and fistula 9-10 is advocated consistently. Etiologies for recurrent pyelonephri- formation may be avoided with rapid diagnosis and treatment.
tis include obstructive process such as kidney stones, Xantho- granulomatous pyelonephritis (XGP) or vesicoureteral reflux.
A CT scan was obtained upon the patient’s second visit These require specialized treatment and generally will not re- to the emergency room, with the radiology reading of: “diffusely spond completely to antibiotics. Additionally, antibiotic choices enlarged kidney with multiple low attenuation areas throughout for the emergency medicine physician should be based on the the renal parenchyma. There is a large staghorn calculus. Find- patient prior cultures, co-morbidities, clinical condition and lo- ings are consistent with XGP (Figure 1).”
cal antibiogram for urinary pathology to name a few factors. Ap- propriate emergency department management of concomitant A subsequent outpatient cystourethroscopy and right conditions, discomfort and dehydration may also be indicated.
retrograde pyelography was attempted but was unsuccessful.
XGP can present with vague non-pathognomonic symptoms of flank or abdominal pain, fever and anorexia and dysuria. It On the first and second emergency department visits is frequently associated with anemia, seen in 66-100%, leuko- the patients WBC count and urinalysis was 17000 and 12000 3-7 cytosis, 61-90%, and in up to 35% of cases pyuria is absent.3-7 with bacteria pyuria and no bacteria or pyuria respectively.
Suppuration of kidney tissue results from abnormal macrophage response to infection resulting in necrosis, lipid accumulation, A urine culture obtained from the patients first emer- and vascularized granulation tissue formation. This tissue is gency department visit revealed >100,000 colonies/ml of pan- characterized by lipid-filled macrophages lending it the yellow sensitive Pseudomonas aeruginosa.
The patient was treated in the emergency department CT is the diagnostic modality, which was delayed in with IV fluids for presumed dehydration and pain control. She our case, and shows most frequently an enlarged kidney, some- was started on continuous antibiotics to reduce bacterial load, times with the Bear’s Paw Sign of dilated caliceal spaces, often evaluated by urology who concurred with concern for Xantho- with poor cortical perfusion and an associated renal stone.6 Dif- granulomatous pyelonephritis and follow-up with them was ar- ferential diagnosis includes renal carcinoma, non-XGP chronic ranged 1-week later.
pyelonephritis, and renal tuberculosis. Untreated may lead to 1,5,7-8 invasive spread, fistula formation, and systemic infection.
The diagnostic imaging was obtained and the diag- nosis of presumed Xanthogranulomatous pyelonephritis was In this case, the complete destruction of the kidney re- made. She continued on the ciprofloxacin with the resolution
of her symptoms as an outpatient. A cystourethroscopy, right