Beruflich Dokumente
Kultur Dokumente
517
CT and Sonography
Severe
Renal and
Infections
William
Hoddick1
R. Brooke
Jeffrey12
Henry
I. Goldberg1
Michael
P. Federle12
Faye
C. Laing12
Acute
pyelonephnitis
pniate antibiotic
therapy.
in most adult
patients
In patients
unresponsive
radiologic
is warranted
renal
investigation
abscess.
the primary
Most
Until
recently
methods
used
usefulness
of CT and
however,
in evaluating
methods
in
sonographic
renal
patients
During
Department
nia,
San
18, 1 982:
of Radiology,
Francisco,
accepted
University
October
of Califor-
CA 94143.
of Radiology,
1001 Potrero
San Francisco
General Hospital,
Ave., San Francisco,
CA 94110. Address reprintrequests to R. B. Jeffrey.
AJR 140:517-520, March 1983
0361 -8o3x/83/1
403-0517
$00.00
American
Roentgen
Ray Society
with
in 1 2 such
possible
with
obstruction
angiography
suspected
or a
have
renal
been
abscesses.
both
renal
comparisons
renal
abscesses.
patients
and
review
and
penirenal
between
We
the
infections
report
the
noninvasive
CT
and
imaging
of
and Methods
the
period
between
January
1 979
and
March
1 982,
1 2 patients
were
evaluated
for possible
renal abscesses.
Eleven of the 1 2 patients
had
with an initial diagnosis
of acute pyelonephnitis
(fever, flank
pain,
tract
and
therapy.
mia.
2Department
in evaluating
findings
ureteral
and
after appromanagement,
pyelonephnitis
will have normal excretory
urograms,
such as a renal mass, comhave largely supplanted
angiognaphy
as
Several
reports
have documented
the
patients
either
promptly
medical
infections.
Subjects
August
sonography
there
resolve
to initial
urognaphy
patients
[2-7];
will
to exclude
excretory
with uncomplicated
acute
urograms
[1 ]. In patients
with abnormal
puted tomography
(CT) and sonography
the next imaging
method
of choice.
Received
19, 1982.
of
Perirenal
patients
The
documented
urinary
One patient
developed
age
were
range
of
the
infection)
systemic
patients
was
and
a poor
candidiasis
1 0-73
years
response
after
to appropriate
chemotherapy
(mean,
47
years).
antibiotic
for acute
Five
leuke-
of the
12
diabetic.
Downloaded from www.ajronline.org by 111.223.252.43 on 06/25/15 from IP address 111.223.252.43. Copyright ARRS. For personal use only; all rights reserved
518
HODDICK
ET
AU.
AJR:140,
D
Fig.
1 -Diabetic
with
four
staphytococcal
renal
abscesses.
March
1983
A, Left
lower
fascia
mass
(arrows)
without
acoustic
enhancement.
C and 0, Multiple
scesses (arrows)
and E, left renal abscess (arrow)
diagnosed
seen with sonography.
intervals
through
the
kidneys.
The diagnosis
of a renal or perirenal
abscess
was confirmed
by
surgery (six patients) or diagnostic
percutaneous
needle aspiration
(one patient).
In the other five patients,
CT and sonography
demonstrated
focal (two) or multifocal
(three) bacterial
nephritis.
None
of this
group
clinical
improvement
of patients
required
after
surgery
prolonged
and
antibiotic
there
was
gradual
therapy.
Results
Rena!
Abscesses
Three
patients
2 cm (fig.
1 ).
multiple
Bilateral
had
six proven
A fourth
patient
renal
with
bilateral
abscesses
smaller
staphylococcal
abscesses
diabetic
with the smallest
diagnosed
all the renal
abscess
abscesses
abscesses
systemic
larger
than
candidiasis
had
than
1 cm (fig.
2).
were
also noted
in a
about
2 cm. CT correctly
in this series.
With CT,
the renal
abscesses
defined,
low-density
characteristically
parenchymal
adjacent
renal fascia
which
were contiguous
was noted
in three
of the
with peninenal
fat. In two
lesions.
appeared
as
Thickening
well
of
abscesses
abscesses
Fig.
2.-Multiple
arrows).
Multiple
demonstrate
renal
small
renal
hepatic
abscesses
abscesses
systemic
arrow).
candidiasis
Sonography
(black
failed to
lesions.
confined
to the cortex
and
there was no fascial
thickening
Sonography
from
(white
correctly
not
adjacent
(fig. 1 D).
diagnosed
renal
to
peninenal
abscesses
fat,
in two
AJR:140,
March
RENAL
1983
AND
PERIRENAL
INFECTIONS
519
Fig. 3.-A.
Gas-forming
renal and
perirenal
abscesses.
CT also demonstrates focal bacterial
nephritis
(arrow).
Slight enlargement
of left psoas muscle
adjacent
to abscess.
B, Sonogram
ini-
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tially interpreted
Reverberation
in retrospect.
phritis seen
as showing no abscess.
poorly
defined
areas
of decreased
contrast
enhancement
on CT (fig. 5). Sonography
was abnormal
in only two of the
five patients
demonstrating
a focal,
hypoechoic,
solid mass.
In one
of these
involvement.
patients,
Clinical
CT
follow-up
months
demonstrated
ess on
showed
antibiotic
therapy.
interval improvement
showed
in the
resolution
multiple
five
of the
areas
patients
inflammatory
proc-
In two patients,
follow-up
at 4 and 6 weeks. There
a correlation
between
multiple
and a protracted
clinical
course
of
of 6-14
foci of involvement
with more gradual
CT
was
on CT
clinical
improvement.
Discussion
Fig.
4.-Diabetic
with
and sonography.
density
perirenal
abscess
correctly
by both CT
mass containing
lowperirenal
abscess
at
diagnosed
Perirenal
fat obliterated
by soft-tissue
(arrows). Proven Candida albicans
abscesses
surgery.
of
three
patients.
The
abscesses
appeared
as
either
complex
fluid collection
on hypoechoic
mass with poor
through
transmission.
In the patient with systemic
candidiasis, sonognaphy
was normal.
A false-negative
diagnosis
occurred
in another patient with a large abscess in the lower
pole of the left kidney (figs. 1 A-i D) in whom sonognaphy
failed
to demonstrate
three
other
smaller
abscesses.
The
CT correctly
diagnosed
all three patients
with surgically
proven peninephnic
abscesses
(figs. 3 and 4). The CT findings
included
peninenal
bubbles
(one
and thickening
nosed
two
falsely
negative
fluid
collections
patient)
with
of adjacent
of
the
three
(two
patients)
on gas
distortion
of the renal contour
renal fascia. Sonognaphy
diagpeninephnic
in a patient
with
abscesses,
a gas-forming
but
was
peninenal
or Mu!tifoca!
and
and
penirenal
abscesses
radiologists
alike.
be viewed
as
treated
interstitial
a pathologic
infections
evolve
into an acute
abscess.
Although
tenial nephnitis
gradually
improve
with
peninenal
therapy
abscesses
alone.
portance
because
generally
Therefore,
to distinguish
of the potential
jacent
fascia.
series
patients
antibiotics,
do not
respond
interstitial
infection
need for surgical
rounded
areas
Unlike
bacterial
distribution.
Also
Bacteria!
Five patients
were included
exhibited
single (two patients)
Nephritis
in this category.
All patients
on multiple
(three patients)
of the most
the sharp
adjacent
enhancing
poorly
defined
areas
generally
series
as
and
to antibiotic
clinical
im-
from an abscess
intervention.
of renal
abscesses
abscesses,
appear
as
without
significant
contrast
nephnitis,
strongly
abscesses
suggestive
do not
was ad-
peninephnic
extension
with thickening
of the renal
This finding
was not present
in two abscesses
in our
confined
to the cortex
and not contiguous
with pen-
detected
nience,
renal
with bacrenal
or
it is of considerable
In describing
the CT appearance
Rauschkolb
et al. [2] noted that renal
defined,
continues
Severe
continuum,
may liquefy
consistent
demarcation
CT features
among
our
of abscesses
from
renal
panenchyma
of focal bacterial
as opposed
nephnitis.
In describing
the gray-scale
sonographic
abscesses,
Wicks
et al. [1 ] noted
that
abscess.
Focal
may
enhancement.
have a loban
Abscess
of renal
clinicians
infections
inadequately
well
Perinephric
diagnosis
to challenge
must
be at least
by sonography.
as the abscesses
were
2-3
features
renal
cm in diameter
In addition
of renal
abscesses
in order
This is in keeping
with
missed
by sonognaphy
all 2 cm on smaller.
to the
to size
our
to be
expein our
limitations,
520
HODDICK
ET
AJR:140,
AL.
March
1983
Fig. 5.-Multifocal
bacterial
nephritis. A, Enlarged
right kidney with three
poorly defined
areas of decreased
enhancement
(arrowheads).
B, Sonogram
underestimates
extent of involvement
as
only single hypoechoic
area identified
Downloaded from www.ajronline.org by 111.223.252.43 on 06/25/15 from IP address 111.223.252.43. Copyright ARRS. For personal use only; all rights reserved
(arrows).
sonography
alterations
necting
cannot
define
fascial
of peninephnic
diagnostic
needle
scesses,
and
fat.
an aggressive
aspiration
may
filled
peninephnic
sonography.
approach
overcome
abscesses
The
only
thickening
on detect
Sonognaphy
aspiration
of
subtle
is useful
suspected
with
The
in diab-
abscess
missed
with
acute
pyelonephnitis.
Excretory
in this
unognams
in
three of these
patients
were normal.
The authors
concluded
that CT was more sensitive
than excretory
urography
in the
detection
of focal areas of interstitial
infection.
Lee et al. [7]
described
the
CT and
sonognaphic
features
of acute
bacterial
nephnitis
in 1 3 patients.
With sonography,
focal
bacterial
nephnitis
appeared
as hypoechoic
masses
without
definable
poorly
defined,
administration
emphasized
nephnitis
series
mal
low-density
of contrast
enhancement.
tended
as
multiple
negative
evidence
In one
a single
sonography
involvement,
was
clear-cut
of the
area
in
cases
where
areas
in
parenchyCT
the
were
showed
degree
identified.
antibiotic
1 . Wicks
Radio!
2.
3,
4.
5,
6.
7.
8.
of
although
clinical
nephnitis
severity
seemed
and
the
to
need
treatment.
this
is admittedly
a small
series
of
of both
renal
and
penirenal
infections.
REFERENCES
bacterial
patients
bacterial
increased
and further
studies
will need to corroborate
these
it seems that CT is the more sensitive
method for
diagnosis
sonography
infection,
to underestimate
abnormal
three
of abnormal
of focal
bacterial
In our
or multifocal
patients
findings,
to
intravenous
et al. [8]
of acute
focal
via sonography.
focal
focal
areas of
solid
corresponded
areas
on CT after
material.
Rosenfield
with either
sonognaphy
CT showed
demonstrated
that
These
the lobar
distribution
could
be diagnosed
of five patients
nephnitis,
whom
that
walls.
of multifocal
with
In conclusion,
series
was a gas-containing
abscess.
In retrospect,
pennephnic
gas could
be identified
(fig. 3), but this was ovenlooked
on the initial examination.
Hoffman
et al. [6] described
the CT features
in five diabetic
patients
well
for prolonged
percutaneous
some
of these
limitations.
Fluidmay be readily
diagnosed
by
peninephnic
presence
correlate
JD,
Thornbury
Clin North
Am
JR.
Acute
renal
infections
in adults.
1 979; 1 2 :245-260
Rauschkolb
EN, SandIer CM, Sumant P, Childs TU. Computed
tomography
of renal inflammatory
disease.
J Comput Assist
Tomogr 1 982;6 : 502-506
Edell SL, Bonavita
JA. The sonographic
appearance
of acute
pyelonephnitis.
Radiology
1 979;1 32 : 683-685
Gelman
MU, Stone LB. Renal carbuncle:
early diagnosis
by
retropenitoneal
ultrasound.
Urology
1976;6: 103-107
Schneider
M, Becker JA, Stniano 5, Campos E. Sonographicradiographic
correlation
of renal and perirenal
infections.
AJR
1976;1 27: 1007-1
014
Hoffman
EP, Mindelzun
RE, Anderson
RU. CT in acute pyelonephnitis
associated
with diabetes.
Radiology
1 980; 1 35 : 691 695
Lee KTL, McClennan
BL, Melson GL, Stanley RJ. Acute focal
bacterial
nephnitis:
emphasis
on grey scale sonography
and
computed
tomography.
AJR 1 980;1 35 : 87-92
Rosenfield
AT, Glickman
MG, Taylor KJW, Crade M, Hodson
J. Acute focal bacterial
nephritis
(acute lobar nephronia).
Radio!ogy I 979;1 32 : 553-561