Presentation
Left loin pain and fever.
Patient Data
A thick walled collection measuring 11 x 8 x 11.7 cm extends from the perinephric space through the pararenal space and into the abdominal wall. The left kidney is displaced anteriorly and measures 12.2 cm. It contains a large staghorn calculus. The parenchyma is thinned with decreased enhancement and extensive rounded radiolucencies. Fat stranding throughout the retroperitoneum. There is mild dilatation and inflammatory stranding of the left ureter; however, no obstructing lesion is identified. Bladder content is hyperdense, thought to relate to previous CT study.
The right kidney measures 12.5 cm and contains simple cysts. Splenomegaly - the spleen measures 17 x 6.5 x 11 cm. No focal lesion. What appear to be loops of small bowel are seen in the pouch of Douglas.
The pancreatic duct is dilated (5 mm), however, no intra- or extra-hepatic biliary dilatation is seen. Pancreatic duct dilatation appears to extend to the ampulla without an obstructing lesion identified.
Gallbladder and adrenals are unremarkable. No free intraperitoneal gas or fluid. Lung bases are clear.
No aggressive bony lesions. Right hip prosthesis with associated artifact noted. No CT evidence of osteomyelitis/discitis.
Films obtained following perinephric abscess drainage. Large staghorn calculus with several noncontiguous large calculi filling dilated renal calyces in the left kidney. The left renal shadow is enlarged. Pigtail drainage catheter projects over the left inferior pole, compatible with abscess drainage catheter. No right-sided renal tract or ureteric calculi. Hyperdense fecal material in the left-sided colon and rectum compatible with mixed enteric contrast.
Once the acute infection had subsided, with drainage and antibiotics, the patient went on to have a nephrectomy.
The patient went on to have a left nephrectomy.
Histology
MACROSCOPIC DESCRIPTION:
MICROSCOPIC DESCRIPTION:
FINAL DIAGNOSIS:
Case Discussion
This case demonstrates typical appearances of xanthogranulomatous pyelonephritis complicated by a large perinephric abscess. The abscess was drained before nephrectomy and yielded Proteus mirabilis.
Gross pathology image courtesy of Dr Alpha.Tsui, Royal Melbourne Hospital.
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