Renal abscess

• 11 Mar 2020 04:51:37 PM
• |General Urology

25 years old lady presented with pain in left flank. History of trauma three weeks ago. Developed fever after five days. Was admitted and had received injectable antibiotics.  USG was suggestive of left renal abscess. Abscess had marginally increased in size in follow up USG (certainly had not decreased).

Comments(8)

• 

  Dr. Anil Takvani

  12 Mar 2020 08:03:32 AM

  THis appears to me abscess formation in infected haematoma following trauma to kidney.

  Abscess wall is not smooth as we see in cysts.

  Whatever etiology, abscess is big and will require percutaneous insertion of tube.

  Please tell us what exactly you did; have you inserted tube?, Was there pus? How much it has drain? At present output and still pus or urine?

  
  

  Thanks

• 

  Jaideep Mahajani

  12 Mar 2020 09:10:59 AM

  Abscess was drained percutaneous. Immediately after putting nephrostomy tube in the cavity 30 blood stained pus flakes were drained. Pus was cleared in two days and it started draining 200 to 300 ml urine in 24 hours. 

  After twelve days USG shows complete collapse of cavity, but is still draining 100 to 150 ml urine. 

  What should be done now?

  1.Remove the drain

  2.Do contrast study, and if cavity is communicating  with PC system, put DJ stent and then remove drain. 

  3. Wait for few more days, hoping the drain will stop, and the remove the drain. 

  Thanks. 

• 

  Dr. Roy Chally

  12 Mar 2020 01:53:56 PM

  Abscess in a moiety is a possibility. Nephrostogram should be helpful. 

• 

  Dr. Anil Takvani

  12 Mar 2020 02:59:54 PM

  Jaydeep,  if possible do Antegrade study and post the image... Thanks 

• 

  Venugopal P

  14 Mar 2020 11:41:10 AM

  Dear All,

  Margaret Starnes et al (2010) found renal abscess development in 0.3% of nearly 1000 cases of renal injury and hence incidence of renal abscess post renal trauma is uncommon. The Picture provided is suggestive of the collection in the region of upper pole which probably led Roy to consider the possibility of an Abscess in a moiety. His suggestion of performing a nephrostogram can clarify the situation as to whether the cavity is open or closed in view of the Continued Urine drainage from the catheter.

  Such an appearance of the CT (provided), if the history of Trauma was not available, one should have suspected a Pyocalyx most probably due to TB with Upper calyceal Infundibular stenosis. This is one condition where development of fistula can occur after drainage.

  It is surprising that there is no mention of the organism grown. I am sure this was done but not mentioned. In India, in many of these inflammatory collections, it is justifiable to perform AFB culture as well.

  With trainees in mind (not omitting others), I am digressing from the topic on hand.

  When we discuss regarding Renal Abscess, a discussion on Perinephric Space should also be done.

  Though several radiology reports especially CT, mention perinephric stranding, mostly associated with Inflammatory and Neoplastic lesions within the kidney, a good knowledge of this is lacking.

  There are 3 types of Kunin’s septa described. They are:

  Type 1 – Connect the Renal capsule with the Renal Fascia

  Type 2 – are attached only to the renal capsule and course parallel to the surface of the kidney

  Type 3 – are the common type. They connect the Anterior Renal Fascia with the Posterior Renal Fascia.

  (The renal capsule is a tough fibrous layer surrounding the kidney)

  BH Eisner, Matthew R Cooperberg, Marshall L Stoller et al (2010) found Gender differences in subcutaneous and Perinephric fat distribution. They concluded stating that ‘Women exceed men in subcutaneous fat, while men exceed women in perirenal fat. Obese patients are very likely to have large amounts of subcutaneous fat, but will not necessarily have proportionally increased fat around their kidneys when compared to the patients with lower BMI. These differences may have important implications for surgical approaches to the kidney’.

  https://escholarship.org/content/qt9z1613x9/qt9z1613x9.pdf?t=o9w552

  Goran Mitreski & Tom Sutherland (2017) have given us a pictorial essay on ‘Radiological diagnosis of perinephric pathology’ which is must read and understanding.

  https://link.springer.com/content/pdf/10.1007/s13244-016-0536-z.pdf 

  There are two drawings provide along with several radiographic images. The first one represents the Perinephric space and the second give us the lateral longitudinal representation of Perinephric Space.

  With warm regards,

  Venu

   

• 

  Jaideep Mahajani

  14 Mar 2020 10:57:10 PM

  Thank you sir for your valuable suggestions. 

  Unfortunately I did not send the pus for AFB culture, as I didn't suspect GU Kochs. Will get urine AFB culture done.

  Patient was not willing for contrast study. So I waited for four days. Fortunately drainage in last three days was nil. Hence drainage tube was removed. She is under followup.

  Regards. 

• 

  Jaideep Mahajani

  15 Mar 2020 07:39:30 AM

  I request Anil, try to remove the fallacy in the software. At times complete text doesn't  appear on the page. 

  Thanks. 

• 

  Venugopal P

  15 Mar 2020 07:50:05 AM

  Dear Jaideep,

  You seem to have drained the abscess and probably it has settled down.

  However as Roy suggested a Nephrostogram would have been worthwhile to note if there is any communication with the PCS. If there is an infundibular stenosis, even Nephrostogram can fail to demonstrate the communication.

  I would suggest that you do a US atleast to detect any perinephric collection, now that you have removed the Drainage tube.

  I would also suggest an RGU when he returns for followup as if there is a cutoff sign; it will contribute to a diagnosis of Infundibular stenosis. If present, it will be in favour of a Pyocalyx rather than a renal abscess.

  With warm Regards,

  Venu