Upper Urinary Tract. Infection

Diagnostic and Interventional Imaging (2012) 93, 509—519
CONTINUING EDUCATION PROGRAM: FOCUS. . .
Imaging in upper urinary tract infections

J. Ifergan , R. Pommier , M.-C. Brion , L. Glas ,
L. Rocher , M.-F. Bellin ∗
General Radiology Department, Bicêtre Hospital, AP—HP, University Paris Sud,

78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
KEYWORDS Abstract Most infections of the upper urinary tract are straightforward and do not require
Kidney; any emergency radiological investigations. A sonogram carried out within 48 hours will in most
Infection; cases be sufficient to eliminate obstructed pyelonephritis requiring emergency drainage of
Sonography; urine. In complicated cases, or those affecting already weakened areas, an urgent CT scan is
Computed necessary, preferably after injection of iodinated contrast medium if renal function permits.
tomography; CT scanning is far better at diagnosis than sonography as well as at investigating whether there
MRI are complications. Furthermore, it is essential that the radiologist is aware of unusual and rare
forms of pyelonephritis, especially pseudotumoural forms, so that clinicians can be pointed
towards the appropriate treatment, avoiding unnecessary and invasive interventions.
© 2012 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
Infections of the upper urinary tracts (kidneys, pelvicalyceal system and ureters) must be
distinguished from infections of the lower urinary tracts (bladder and urethra), which are
very common and do not require radiological investigation.
Although upper urinary tract infections are usually straightforward or
‘‘uncomplicated’’, they can potentially be serious if there is an obstruction or if
they develop in patients who are at risk of complications in that area (Boxed text 1). The
aim of imaging is to eliminate complications, the main one being obstruction requiring
urgent intervention for drainage [1—3]. The majority of community-acquired urinary
infections are caused by Gram-negative bacilli (GNB), usually Escherichia Coli (in 85—90%
of cases of pyelonephritis) [4]. Other less common bacteria that can be responsible are
the GNB Proteus and Klebsielle and the Gram-positive Cocci (GPC) enterococcus and
Staphylococcus aureus. Hospital-acquired urinary infections make up 30% of all nosocomial
infections and are caused by agents that are more virulent and often multiresistant, with
adverse outcomes, in particular Pseudomonas aeruginosa [4]. Two physiopathological
mechanisms can lead to upper urinary tract infections: ascending infection, which is most
common, or haematogenous infection.
∗ Corresponding author.
E-mail address: marie-france.bellin@bct.aphp.fr (M.-F. Bellin).
2211-5684/$ — see front matter © 2012 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.diii.2012.03.010
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510 J. Ifergan et al.
Boxed text 1 Risk factors for upper urinary tract Boxed text 2 Clinical and biological diagnosis of
infection. acute pyelonephritis.
• Immune suppression (AIDS, diabetes, corticosteroid Clinical signs:
therapy, chemotherapy to treat cancer, kidney • Lumbar pain is unilateral more often than bilateral.
transplant), recent treatment with antibiotics for • High temperature (fever of 39 o C).
urothelial saprophyte bacterial flora imbalance, • Pyuria.
urinary catheter. • Functional urinary signs (pollakiuria, dysuria).
• Pregnancy. • Positive urine dipstick (screening): positive for
• Obstruction to the urinary collecting system: urinary leukocytes and nitrites.
lithiasis, deformity to the urinary system, urothelial
Biological signs:
neoplasm, bladder neuropathy. • Cytobacteriological urine examination (urinalysis,
diagnostic): bacteriuria ≥ 105/mL, leukocyturia ≥
104/mL and antibiogram.
In ascending route infections, the infected urine from • Inflammatory signs (polynucleosis, raised CRP and
the lower urinary system reaches the papillae and then procalcitonin).
the collecting ducts. This involvement of the ducts causes
vasoconstriction of the arterioles and inflammatory oedema
leading to ischaemia. This mechanism explains why sys-
tematised lesions are seen on contrast-enhanced computed or laboratory results indicative of a serious infection, or
tomography. When, more rarely, infection is spread to the where patients deteriorate, a CT scan must be carried out
kidney by the haematogenous route, this is the result of a urgently. Plain film radiography is still indicated where
septic localisation in a patient with septicaemia. In cases dilation of the pelvicalyceal system is seen on sonography
of haematogenous infection, the infective agent reaches with no detectable calculi. If a plain film radiogram remains
the renal cortex and subsequently the renal medulla within inconclusive, a CT scan is indicated urgently [5].
24—48 hours, in contrast to the mechanism of ascending
route infection in which the bacteria reaches the papilla Objectives of imaging investigations
directly. In the former case, urinalysis may be negative
The diagnosis of pyelonephritis rests solely on clinical crite-
as long as there is no communication with the collect-
ria (fever, functional urinary signs, lumbar fossa pain, urine
ing system. Lesions are rounded and peripheral, without
dipstick positive for leukocytes and nitrites) and laboratory
lobulation. This type of pyelonephritis may manifest as a
results (positive urinalysis, and sometimes blood cultures
pseudotumour and the absence of bacteria in the urine does
are also done) (Boxed text 2) [4]. The two purposes of imag-
make differential diagnosis challenging.
ing are:
• to look for any complications that would need specific
therapeutic management (obstruction of the collecting
Which radiological investigations and why?
system requiring diversion of the urine, an abscess or
Uncomplicated pyelonephritis perirenal fluid collection leading to drainage or a change
of antibiotic regimen);
In the majority of cases, pyelonephritis is ‘‘uncomplicated’’ • to identify rare forms of pyelonephritis in an atypical clin-
and does not require any emergency radiological investiga- ical presentation or with atypical laboratory results.
tions. It is desirable to carry out a sonogram of the urinary
tracts as soon as possible (ideally within 24 hours) and this
should be sufficient to detect any obstructions that may What is the role for the different imaging
require urgent drainage [1]. techniques?
Pyelonephritis is referred to as ‘‘uncomplicated’’ when
it occurs in a nonpregnant woman aged between 15 and 65, Doppler sonography
with no signs of being serious, no functional or anatomical
abnormalities of the urinary system, and crucially with no The main purpose of sonography is the detection of dilation
sign of obstruction, no recent intervention to the urinary sys- in the pelvicalyceal system, although this finding is not
tem, no recent or recurring episodes of pyelonephritis, and always synonymous with an obstruction. Hypotonia of the
no current illness affecting the patient’s immune status [1]. urinary tracts can be seen in pregnancy, together with
vesico-ureteric reflux, megaureter or hyperdiuresis. On the
Complicated pyelonephritis other hand, if dilation is not seen, this does not neces-
sarily eliminate an obstruction, because the appearance
If a case does not meet all of the above criteria, it is of obstructions can be delayed in relation to the onset
considered to be a ‘‘complicated’’ infection. In men, symptoms.
the infection is by definition ‘‘complicated’’ and the Sonography is of minimal value to detect foci of nephri-
cause, which could be prostate involvement or another tis. However, this can be improved by using high frequency
obstructive cause of the lower urinary system, must be and Doppler waves. Foci of nephritis will then appear as per-
investigated by pelvic sonography. If there are clinical signs fusion defects on colour Doppler, using low velocity scales.
Imaging in upper urinary tract infections 511
Increased kidney size and perirenal infiltration cannot be Intravenous urography (IVU)
readily assessed and are often missed. Although intrarenal
or perirenal abscesses can be visualised on a Doppler sono- Intravenous urography is no longer indicated in acute
gram, the CT scan remains the reference examination for pyelonephritis [4]. It has increasingly been replaced by CT
detecting them. In our experience, using a contrast medium urography. It is still used by some to investigate infec-
in sonography does not significantly improve detection of tious and inflammatory urothelial pathologies and urothelial
foci of nephritis or potential complications. tumours.
CT scan [6] Retrograde and urinary urethrocystography

CT investigation of pyelonephritis requires a precontrast This allows vesico-ureteric reflux to be investigated when
spiral CT scan, followed by, assuming there are no con- there is clinical suspicion as well as looking for any obstruc-
traindications, a contrast-enhanced spiral CT scan, in the tion to the lower urinary tracts.
tubulo-interstitial phase, preferably 90 to 120 seconds after
the injection (tubular venous phase acquisition). A delayed
phase acquisition at the excretory phase is not usually neces- The different forms of acute
sary. The CT scan without contrast injection enables calculi, pyelonephritis and their complications
wall calcifications (encrusted pyelitis and bilharziasis), and
the presence of gas (emphysematous pyelonephritis) or Pyelitis
blood to be detected. This examination is very sensitive to
dilation of the pelvicalyceal system, and it is all the more Isolated pyelitis and pyeloureteritis point to inflammation of
useful in patients who present challenges to sonographic the mucosa and the collecting system (Fig. 1 a, b). On sonog-
exploration. raphy this appears as echogenic and even thickening around
The tubulo-interstitial phase is the most sensitive for the circumference of the walls of the collecting system. This
detecting abnormalities of the parenchyma and it is impor- thickening is also seen on CT and MRI scans, but sonography
tant to use narrow windows to read the examination. This is usually sufficient to put forward this diagnosis.
is because when windows are set too wide this tends to blur
the slight differences in density and therefore runs the risk Uncomplicated pyelonephritis
of missing abnormalities.
When the urinary epithelium is affected this can spread to
MRI the renal parenchyma (Fig. 2). We have seen that diagnosis
is usually made clinically and that sonography is normally
MRI is useful where there is a contraindication to iodine- sufficient to investigate whether there is any obstruc-
containing contrast injection, such as renal failure or in tion in the urinary tracts. However, there are numerous
pregnant women, and it provides the same information as CT descriptions of CT investigations. CT scan without contrast
scanning. Diffusion MRI is very sensitive for the noninvasive injection shows an enlarged kidney with infiltration of the
detection of focal areas of pyelonephritis. perirenal space fatty tissue. But radiological diagnosis of
Figure 1. Bilateral pyelitis: a: in the axial plane; b: in the sagittal plane. Even thickening and contrast uptake in the walls of the renal
pelvis (white arrow). The presence of cortical defects is visible and this corresponds to the sequelae of pyelonephritis (arrow-head).
Boxed text 3 Differential diagnosis of a renal

abscess.
• Superinfected kidney cyst.
• Infected congenital renal diverticulum.
• Superinfected kidney tumour.
• Papillary necrosis.
the significance of the lesions, can point diagnosis in the

right direction [8].
Pyelonephritis through haematogenous spread

In cases of haematogenous spread to the renal parenchyma,
the lesions are as a rule rounded, located in the cortex, often
Figure 2. Uncomplicated pyelonephritis. Right pyelonephritis on bilateral, sited at a distance from the collecting system, and
a contrast-enhanced CT scan of the abdomen and pelvis in the tubu- without segmentation or lobulation.
lar venous phase: the renal parenchyma has a ‘‘spoked wheel’’
appearance. Acute focal bacterial nephritis (AFBN) [9]
pyelonephritis rests on contrast-enhanced CT scanning. Mul- This is a form of pyelonephritis with adverse outcomes
tiple areas can readily be affected, and in most cases lesions that can be caused by ascending or haematogenous infec-
are well-defined, wedge-shaped areas with their bases at tion. A pseudotumoural inflammatory mass forms, that takes
the periphery and apexes towards the renal sinus, with up contrast, and sometimes shows an element of necrosis
the renal parenchyma sometimes demonstrating a striated [10] (Fig. 5 a—d). In the absence of any clinical sign-
appearance. These abnormalities indicate hypoperfusion posting, it can be difficult to distinguish from a tumour.
secondary to arteriolar vasoconstriction and inflammatory The finding of an atypical renal mass must lead the clin-
response. However, there is a delay in the lesions taking up ician to suspect AFBN as this could avoid an unnecessary
the contrast, which can sometimes be several hours after nephrectomy, since the majority of patients progress well on
the injection, as shown by a delayed nephrogram (Fig. 3). antibiotics.
The main differential diagnosis to be eliminated is renal
infarction (Fig. 4 a, b). The clinical context is very different Renal abscess [11]
in these cases (cardio- or polyvascular disease, sudden onset
of lumbar pain preceding a low-grade fever 24 to 48 hours Unless an infection is serious, it is rare for abscesses to
later) [7]. There are no clinical, microbiological or biological develop (Fig. 6 a, b). Only renal sonography can make the
signs of urinary infection (although sometimes microscopic diagnosis for certain when the finding is a mass contain-
haematuria with no bacteria is reported). A fine layer of ing some degree of fluid. On colour Doppler, peripheral
cortical enhancement, the ‘‘cortical rim sign’’, is highly increased vascularisation is demonstrated, with the mass
suggestive of this diagnosis. The outer renal cortex is in causing backflow into the interlobular and arcuate arteries.
this case vascularised by capsular perforating vessels, which An abscess can, however, also present as an echogenic
are in turn fed by the inferior phrenic arteries, the middle mass: in this case diagnosis on sonography is difficult and a
suprarenal arteries and the gonadal arteries. contrast-enhanced CT scan is essential for diagnosis to be
In difficult cases, only the finding of minimal or absent made [12]. In all cases, sonography is less sensitive than
infiltration of the perirenal fatty tissue, which contrasts to CT for assessing spread to the perirenal space. On views
without contrast medium injection, an abscess appears
as a fluid-filled renal mass with attenuation coefficients
varying between 0 HU and 30 to 40 HU. Sometimes the
presence of gas is detected. After injection of contrast
medium, the capsule of the abscess is thick and enhanced,
although the fluid inside does not enhance. The external
part of the capsule of the abscess can appear irregular
due to associated inflammatory infiltration. On delayed
studies (an hour or more), a ring or strip of delayed
nephrogram can surround the fluid collection. This delayed
nephrogram has the same meaning as those seen in acute
pyelonephritis and corresponds to blocked tubules with
backflow.
Figure 3. Delayed nephrogram. Delayed studies, sometimes sev-
eral hours after the injection, can show an inversion of the lesions: The main differential diagnoses are diverticula, cysts
the sites of nephritis that were initially hypodense become hyper- (Fig. 7 a, b) and infected necrotic tumours (Boxed text 3). In
dense. the absence of any relevant history, the diagnosis is usually
Figure 4. Right kidney infarction: a: in the axial plane; b: in the coronal plane. Wedge-shaped enhancement defect of the posterior lip of
the right kidney on a contrast-enhanced CT scan, with cortical contrast uptake showing the ‘‘cortical rim sign’’ (white arrow), confirming
that ischaemia is the mechanism of the lesion.
made retrospectively: after treatment with antibiotics, the

inflammatory signs regress and expose any underlying cysts, Boxed text 4 Causes of obstruction of the urinary
tumours or diverticula [13]. collecting system.
When the abscess is small (< 3 cm diameter), treat- • Endoluminal obstruction: urinary calculi, papillary
ment with antibiotics should lead to resolution; otherwise,
necrosis, blood clots in the urine, mycelial
ultrasound—or CT-guided drainage is indicated in combi-
accumulation.
nation with antibiotics [7]. If left untreated, the abscess • Wall abnormality: tumour stenosis, infections
could spread to the perirenal space: this is a perinephric
(tuberculosis, bilharziasis), postradiation.
abscess. • Extrinsic obstruction: pregnancy, pelvic tumours
(such as a cervical tumour invading the pelvis),
Perinephric abscess [14,15] retroperitoneal fibrosis.
This is when a renal abscess ruptures out of its capsule. It

moves readily into the perirenal space and, by diffusion, into
other retroperitoneal space and the abdominal wall. A CT Emphysematous pyelonephritis [17—22]
scan is required for diagnosis in order to identify its precise
location and assess its spread. The specific treatment usually This particularly serious form of pyelonephritis most often
involves percutaneous drainage. occurs in patients with diabetes. It often has adverse out-
comes and may lead to a nephrectomy. The bacterium that is
most commonly the cause is E. coli (70% of cases), but other
Pyonephrosis [16] bacteria can be responsible. The bacteria cause glucose fer-
mentation, which leads to the formation of gas, and this
Pyonephrosis is a concomitant suppuration of the process is encouraged by the presence of sugar in necrotic
parenchyma and the collecting system, and in most tissue and in the urine.
cases it leads to compromise renal function. It is usually The clinical picture is one of a case of acute pyelonephri-
secondary to a calculus and more rarely to other causes of tis that does not respond to treatment and that can quickly
obstruction (Boxed text 4). Sonography and CT scan without progress to septic shock. A varying degree of renal failure
contrast injection demonstrate dilation of the pelvicalyceal is often reported. A CT scan without contrast injection is
system. Other signs can help lead the diagnosis, such the key examination for diagnosis, based on the presence
as thickening of the walls of the renal pelvis and the of gas in the renal parenchyma (Fig. 8 a, b), the urinary
presence of fine mobile or sloping echoes in the calyces tracts and sometimes the perirenal tissue. Contrast medium
on sonography. But these signs may not be present and, in injection is often contraindicated due to diabetes or renal
cases with strong suspicion based on clinical examination failure, but it does allow an assessment of the extent
or laboratory tests, microbiological examination of the of renal parenchyma destruction. If gas is only present
urine and then urine drainage will allow this diagnosis to be in the collecting system, this could point to a case of
made. emphysematous pyelitis, which has a less severe prognosis.
Figure 5. AFBN of the left kidney. Pseudotumoural left kidney mass, made up of tissue combined with multiple hypodense microabscesses:
a: on sonography; b: on contrast-enhanced ultrasonography; c: on contrast-enhanced CT scan in the tubular venous phase; d: on contrast-
enhanced CT scan in the arterial phase.
Figure 6. Renal abscess: a: axial view; b: coronal view. Fluid-filled collection in the left kidney, with septations and thick walls seen on
a contrast-enhanced CT scan.
Figure 7. Superinfected right kidney cyst. Even thickening and contrast uptake in the wall of a right kidney cyst: a: fine septations within
the cyst (white arrow); b: oedema of the perilesional parenchyma (arrow-head).
Figure 8. Early emphysematous pyelonephritis. Intraparenchymal gas bubbles found (white arrow) on CT scan: a: CT scan of the abdomen
and pelvis without contrast medium; b: wide window (pulmonary parenchyma).
Alternatively, the isolated presence of gas in the collecting

system can sometimes relate to a recent catheterisation or Boxed text 5 Causes of hypotonia of the urinary
a uro-intestinal fistula. collecting system without obstruction.
• Pregnancy (pelvi-ureteric dilation as far as the cross
Pyelonephritis in pregnancy with the iliac vessels and more commonly on the
right).
Pyelonephritis in pregnancy can have a poor prognosis • Vesico-ureteric reflux.
because of maternal complications (severe sepsis) and • Hyperdiuresis.
foetal complications (threat of premature birth) (Fig. 9 • Megaureter.
a—d). A sonogram is the first-line investigation used to look
for an obstruction. In cases of physiological dilation of the
collecting system due to pregnancy, the ureter is dilated as
far as the crossing with the iliac vessels and no obstruction particular diffusion imaging, which can readily visualise the
is found. This dilation is predominantly right-sided in 85% zones of pyelonephritis.
of cases and is seen in 90% of pregnant women in the
third trimester of pregnancy (Boxed text 5). However, if Papillary necrosis [23]
sonography confirms the presence of an obstruction, espe-
cially a calculus, the calyces should be drained urgently. To This is a rare complication of ischaemic origin that is
diagnose pyelonephritis in pregnancy, a Doppler sonogram encouraged by infections, usually occurring in diabetic
is carried out as a first-line investigation. If there is any patients [24] and more rarely in patients with sickle
doubt or if an obstruction needs to be better visualised, cell anaemia. The diagnosis rests mainly on IVU and
MRI should be used because it does not emit radiation. CTU, which shows one or several images of accumulation
Acquisitions without contrast injection are prioritised, in in the pelvicalyceal system corresponding to necrotic
Figure 9. Pyelonephritis in pregnancy. Pyelonephritis of the right kidney of a pregnant woman 31 weeks since LMP: a: focal nephritis on
sonography (white arrow): slightly hyperechoic and nonhomogenous cortical lesion of the mid right kidney (white arrow); b: the focal area
is shown to be hypoperfused on a power Doppler scan. The zone before the ureters cross the iliac vessels (head of white arrow) does not
show an obstruction: it is a physiological dilation due to pregnancy; c: on sonography; d: on colour Doppler sonography.
renal papillae sloughed off from the rest of the renal small in size, with dedifferentiation of the renal cor-
parenchyma. tex and medulla and the presence of cortical notches. If
the patient’s renal function permits, a contrast-enhanced
Chronic pyelonephritis CT scan will lead to diagnosis. It demonstrates the
pyelonephritis scar tissue, which combines cortical retrac-
When acute pyelonephritis occurs repeatedly, usually in tion with deformities of the calyces, with areas in between
relation to occult vesico-ureteric reflux, this can lead that are comparatively healthy. If there is no specific
to the patient developing fibrosing interstitial nephri- affected area, a retrograde cystography must be car-
tis (Fig. 10 a, b). Very often it progresses slowly into ried out to investigate whether there is vesico-ureteric
renal failure. On sonography, atrophied kidneys appear reflux.
Figure 10. Chronic pyelonephritis: a: axial view; b: coronal reconstruction. Pyelonephritis scar tissue combining cortical retraction (white
arrows) and deformation of the calyces with areas in between that are comparatively healthy seen on contrast-enhanced CT scan.
Rare forms of urinary infection the bladder, which differ from the transitional cell carcino-
mas that are more usually encountered in the bladder.
Imaging can also lead to a precise diagnosis of some rare
kinds of upper urinary tract infection, which may have an Corynebacterium infection: pyelitis and
atypical presentation on clinical examination or laboratory encrusted cystitis [29,30]
tests.
This is a nosocomial infection that is caused by Corynebac-
Xanthogranulomatous pyelonephritis [25,26] terium urealyticum D2 or more rarely Ureaplasma ure-
alyticum bacteria colonising the urinary tracts of immune
This is a rare form of chronic kidney infection that can be suppressed patients. It can develop in kidney transplant
identified histologically, combining the lesions of chronic patients; it is also encouraged by the prolonged presence
pyelonephritis and xanthogranulomatous foam cells. The of medical equipment (urinary catheter, ureteric stent or
main cause of this type of infection is chronic obstruction nephrostomy). It leads to the formation of ammonium mag-
of the collecting system by lithiasis that often forms in the nesium phosphate calculi that become encrusted in the
shape of staghorns. The bacteria that cause it, when they mucosa of the renal pelvis and ureter. CT scanning without
are found, are Proteus Mirabillis and E. Coli. The obstruc- contrast medium is the best technique for visualising these
tion can also be due to ureteral stenosis of infectious origin wall calcifications. The urothelial wall is thickened and, in
(tuberculosis, bilharziasis), to stenosis of the pelvi-ureteric severe infections, the perinephric and periureteric regions
junction secondary to malformative uropathy, or more have a striated appearance.
rarely, to a tumour of the collecting system. It manifests
in two forms, the most common being diffuse involvement Urinary candidiasis [31,32]
and the other, focal pseudotumour. In the diffuse form, the
symptomatology is often the same as that of pyonephrosis. The urinary system can be colonised by Candida Albicans
The presence of staghorn calculi possibly in the calyces either by the ascending or haematogenous route in immune
is also suggestive. The renal architecture can be entirely suppressed patients. Based on the clinical presentation and
destroyed. The CT scan can also be useful to assess the laboratory results, it is sometimes difficult to distinguish
perirenal spread of the infectious process and any fistulae a colonisation from an infection. However, the presence
complicating it. In the localised form, CT scan findings are of Candida is always pathological. If it is present this
a nonenhancing or minimally enhancing renal mass, usually points to systemic candidiasis and renal involvement is likely
combined with staghorn calculi. This finding can mimic that where it is also present in the urine. Sonography detects
of a renal tumour. accumulation of mycelia with a variable appearance: hyper-
echoic, minimally echoic or slightly echoic. On CT scanning,
Urinary tuberculosis [27] the mycelial accumulation does not take up the contrast
medium. It has a rolled appearance when it contains gas
The kidneys can be affected in miliary tuberculosis due to between the layers of fungal colonies. When gas is absent,
the dissemination of Koch’s bacillus through the haematoge- it appears as an aspecific but mobile solid mass. On an
nous route. It can progress to form areas of ulcerating excretory phase CT scan, a filling defect in the collecting sys-
parenchyma in the calyces, making ‘‘cavities’’. The spread tem can be seen. This is also visible on IVU or pyelography.
of bacilli in the urine can then lead to urothelial ulceration, Lesions of the renal parenchyma do not show any specific
followed by scar tissue stenosis. When these stenoses arise, features.
they are usually located at either extremity of the ureter:
the pelvi-ureteric junction or vesico-ureteric junction. CT Renal hydatidosis [33]
scan urography demonstrates accumulation in the calyces
corresponding to fistulised cavities, calyx stem stenosis It is rare for hydatidosis to affect the kidneys. Different
with proximal ball-shaped hydrocalyx, ureteral stenosis and, stages, corresponding with those described by Gharbi con-
more rarely, calcifications of the parenchyma with a ‘‘putty cerning the liver, may be encountered. A contrast-enhanced
kidney’’ appearance. CT scan is the investigation of choice: it demonstrates a
fluid-filled mass that sometimes contains septations (daugh-
Bilharziasis or urinary schistosomiasis [28] ter cysts) and later calcifications.
In this condition parasites and their eggs are present in Pyeloureteritis cystica [34]
the walls of the bladder and ureters, leading to the forma-
tion of multiple granulomas with reactive fibrosis. Recurrent Pyeloureteritis cystica is a rare disease, secondary to dete-
episodes of haematuria are suspicious for this diagnosis. In rioration of the walls of the ureters, usually alongside a
later stages ureteric stenosis develops, as well as calcifica- chronic urinary tract infection. On IVU or CT urography it
tions of the bladder and ureter walls that are readily identi- appears as multiple nonobstructive small filling defects of
fied on CT urography or IVU views without contrast injection. the ureter wall.
If it remains untreated, disease progression leads to a
reduced bladder capacity, to the point of a ‘‘microbladder’’ Malakoplakia [35,36]
appearance combined with an enlarged meatus that encour-
ages reflux, visible on retrograde cystography. Bilharziasis Histologically, this is the development of an inflammatory
encourages squamous cell carcinoma tumours to develop in granuloma secondary to a chronic infection with E. Coli. It is
Figure 11. Contrast-enhanced abdominal CT scan: a: axial view; b: coronal view.
more common in women than in men and it usually affects Questions

the urinary tract. Other forms of this condition (gastroin-
testinal, retroperitoneal etc.) are rare. This disease usually 1. What is your diagnosis?
presents in the form of plaques and less commonly as a mass. 2. Based on the imaging, what kind of bacteria usually
The diagnosis is usually made retrospectively, and it rests on causes this type of upper urinary infection?
histological examination of biopsy tissue. 3. Briefly describe the chronology of this complicated uri-
nary infection.
4. How would you manage this patient?
Conclusion
The majority of cases of pyelonephritis do not require any
additional imaging investigations as an emergency. It is Answers
desirable for sonography of the urinary system to be car-
ried out as soon as possible (preferably within 24 hours), 1. Diagnosis: xanthogranulomatous pyelonephritis of the
because this will be sufficient to detect most obstructions upper pole of the right kidney with a contiguous nephro-
that require urgent intervention for drainage [1]. If serious hepatic fistula proximal to staghorn calculi obstructing
clinical signs or laboratory results are found, the first-line the pelvicalyceal system [37—39].
investigation (except in pyelonephritis in pregnancy) is a 2. Proteus mirabilis. This Gram-negative urease positive
CT scan, which should preferably be contrast-enhanced if bacillus is the bacterium that is most often involved in
the patient’s renal function permits. This performs bet- the formation of ammonium magnesium phosphate (or
ter than sonography at detecting and identifying most struvite) urinary calculi.
complications. It is essential that the radiologist is aware of 3. Chronic urinary infection with a urease positive bac-
unusual forms of pyelonephritis, especially certain pseudo- terium leading to the formation of an ammonium
tumoural forms (xanthogranulomatous pyelonephritis, AFBN magnesium phosphate urinary calculi in the pelvicalyceal
etc.), so that clinicians can be pointed towards the appro- system of the right kidney. Chronic obstruction to urine
priate treatment, avoiding invasive and often unnecessary excretion in the pelvicalyceal system, causing an inflam-
interventions. matory mass to form in the adjacent renal parenchyma.
Extra-renal development of renal parenchyma inflamma-
tion, in the form of a fistula opening with a neighbouring
Clinical case study organ, specifically, in the perirenal fatty tissue, the
renal fascia, the pararenal fatty tissue, then the hepatic
History of the illness parenchyma in segment VI.
4. Appropriate long-term antibiotic therapy based on
A 57-year-old female, with a history of recurrent urinary antibiogram is always indicated. An ultrasound- or CT-
infections, presents a two-month history of right loin pain guided fine-needle aspiration of the abscess may be an
radiating to the right hypochondrium and right shoulder. Uri- alternative to surgery. The advantage of surgery is that
nalysis leads to a diagnosis of urinary infection. In spite of the calculi can also be extracted. A specimen should
a suitable antibiotic regimen, the pain persists and her gen- automatically be sent to pathological anatomy in order
eral condition deteriorates. A contrast-enhanced CT scan of to confirm the diagnosis and eliminate a malignant renal
the abdomen and pelvis is carried out (Fig. 11). tumour.
Disclosure of interest [18] Grayson DE, Abbott RM, Lévy AD, Sherman PM. Emphysema-
tous infections of the abdomen and pelvis: a pictorial review.
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Upper Urinary Tract. Infection

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Diagnostic and Interventional Imaging (2012) 93, 509—519

CONTINUING EDUCATION PROGRAM: FOCUS. . .

Imaging in upper urinary tract infections

General Radiology Department, Bicêtre Hospital, AP—HP, University Paris Sud,

CT scan [6] Retrograde and urinary urethrocystography

Boxed text 3 Differential diagnosis of a renal

the signiﬁcance of the lesions, can point diagnosis in the

Pyelonephritis through haematogenous spread

made retrospectively: after treatment with antibiotics, the

This is when a renal abscess ruptures out of its capsule. It

Alternatively, the isolated presence of gas in the collecting

Figure 11. Contrast-enhanced abdominal CT scan: a: axial view; b: coronal view.

more common in women than in men and it usually affects Questions

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