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XANTHOGRANULOMATOUS PYELONEPHRITIS WITH SPLENIC ABSCESS AND EMPYEMA

Yatindra S Kashid, Nitin D Tawte,Krantikumar R Rathod*, Jayant D Mohite*
Departments of General Surgery and *Radiology, Seth GS Medical College and KEM Hospital, Parel, Mumbai - 400 012.

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Xanthogranulomatous pyelonephritis is a chronic suppurative renal infection, its association with splenic abscess and empyema is scarcely reported. A case with nonfunctioning kidney, splenic abscess and left empyema is presented here. Investigations suggested renal cell carcinoma or pyonephrosis with splenic abscess as possible dignosis. It can mimic malignancy. Final diagnosis can be reached only after histopathology.

 

CASE REPORT

A 40 year old female presented with dull aching left loin pain, fever, vomiting and diarrhoea for three days. There were no urinary complaints. Clinical examination revealed tender upper abdomen with decreased breath sounds and crepitations in left lower chest. Her haemoglobin was 10.1 gm%, WBC count 26,700 per cumm, ESR 67 mm at the end of one hour and BUN was 16 mg%. CT scan revealed nonfunctioning left kidney with multiple calculi and splenic and perinephric abscess, suggesting either pyonephrosis or malignancy (Figs. 1 and 2). At laparotomy, frank pus and dense adhesions were found in left subdiaphragmatic region. Left kidney was studded with pus and spleen was small, friable with necrotic material around it. Left nephrectomy and splenectomy were performed. Postoperatively, she had persistent fever. X-ray chest showed left pleural effusion. Intercostal drainage tube drained pus, which gradually decreased after antibiotic therapy. Urine and pleural fluid showed growth of E.coli. Complete recovery occurred within 26 days. Histopathology showed foamy macrophages (histiocytes) in the kidney diagnosing xanthogranulomatous pyelonephritis with splenic abscess.

Fig 1: CT Scan showing nonfunctioning left kidney with multiple calculi and perinephric abscess	Fig 2 : CT Scan showing the splenic abscess

 

DISCUSSION

Xanthogranulomatous pyelonephritis (XGP) is a rare, chronic renal infection common in middle age diabetic females. Its association with splenic abscess and empyema are scarcely reported. There is extensive destruction of the kidney by inflammatory process, often in nodular configuration with abscess formation. Escherichia coli and Proteus mirabilis are most frequent infecting organisms. [1] CT scan though inconclusive for diagnosisis necessary to assess the frequent extrarenal inflammatory signs which are found in the perirenal space and surrounding area. [2] Bilateral disease though rare is associated with high mortality due to renal failure. [3] Focal involvement is very uncommon. [4] A case with postoperative fever after subcapsular nephrectomy for XGP was found to have splenic abscess a month later, concluding additional risk after such approach. [5] A case of XGP with subphrenic abscess and secondary pleural effusion is also reported. [2] Possibility of renocolic fistulae should be considered in cases of XGP, inspite of absent symptoms and normal barium studies. Such fistulae are treated by nephrectomy and colonic resection. [6] Treatment is total nephrectomy, unless both sides are affected, in which case partial nephrectomy should be preferred. [2] Radical or no excision policies are not safe. If left untreated, XGP may progress to sepsis and fistulae, posing difficulty in management. Clinical features are nonspecific and investigations are inconclusive, only histopathology can reach to conclusion.

In our case preoperative investigations were inconclusive. Total nephrectomy and splenectomy were performed for nonfunctioning kidney and splenic abscess. Empyema was found postoperatively which was treated adequately.

REFERENCES

1.Chuang CK, Lai MK, Chang PL. Xanthogranulomatous pyelonephritis; experience in 36 cases. Journal of Urology 1992; 147 : 333-6.

2.Mendez JV, Castro E, Dorao M, et al. Pleuritic pain and fever. Postgraduate Medical Journal 1997; 73 (856) : 117-8.

3.Luis M. Perez, J Brantley Thrasher, E Everett Anderson. Successful management of bilateral xanthogranulomatous pyelonephritis by bilateral partial nephrectomy. Journal of Urology 1993; 149 (1) : 100-2.

4.Osca JM, Peiro MJ, Rodrigo M, et al. Focal xanthogranulomatous pyelonephritis : Partial nephrectomy as definitive treatment. European Urology 1997; 32 (3) : 375-9.

5.Parra Muntaner LE, Gomez Cisneros S, Kilani Elmasri S, et al. Splenic abscess secondary to xanthogranulomatous pyelonephritis. Archivos Espanoles de Urologia 1995; 48 (8) : 850-2.

6.Majeed HA, Mohammed KA, Salman HA. Renocolic fistula as a complication of xanthogranulomatous pyelonephritis. Singapore Medical Journal 1997; 38 (3) : 116-9.

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