Renal and perinephric abscess

Aug 2, 1996

Alain Meyrier, MD Dori F Zaleznik, MD

UpToDate performs a continuous re ie! of o er 2"# $ournals an% ot&er resources' Up%ates are a%%e% as important ne! information is pu(lis&e%' T&e literature re ie! for ersion 9') is current t&roug& August 2##1* t&is topic !as last c&ange% on August 2, 1996'

PATHOGENESIS A renal or perinep&ric a(scess is no! an uncommon infection of t&e urinary tract' +t can %e elop (y one to t!o general mec&anisms, &ematogenous sprea%, !&ic& usually results in a cortical a(scess* an% ascen%ing infection from t&e (la%%er, !&ic& primarily in ol es t&e me%ulla in most cases -1,2.' Hematogenous spread / 0ematogenous see%ing from (acteremia most often causes a cortical a(scess (ecause t&e corte1 recei e% appro1imately 9# percent of t&e renal (loo% flo!' +n t&e preanti(iotic era, a renal a(scess 2also calle% a renal car(uncle3 or multiple miliary a(scesses !ere a classic complication of 4tap&ylococcal septicemia t&at typically %e elope% one to eig&t !eeks after t&e initial infection -).' T&is form of renal a(scess is no! rare, since stap&ylococcal infections are, in most cases, treate% early in t&eir course' 5enal a(scess can, &o!e er, still (e seen in certain settings, suc& as an intra enous %rug a(user !it& stap&ylococcal en%ocar%itis -6.' 0ematogenous sprea% can also occur !it& sepsis originating from t&e contralateral ki%ney -7. or from e1trarenal sources' +t can, for e1ample, occur in a patient !it& no sepsis !&o suffere% from a seemingly minor skin lesion, suc& as stap&ylococcal pyo%erma -6.' T&ese patients may &a e &a% no clinical e i%ence of systemic infection' Ascending infection / At present, ascen%ing infection accounts for more t&an "7 percent of renal an% perinep&ric a(scesses -2.' Ascen%ing infection, usually %ue to gram negati e organisms, (egins in t&e (la%%er an% ascen%s to t&e renal parenc&yma -1.' T&e resultant acute pyelonep&ritis is follo!e% (y li8uefaction !&ic& !alls off t&e center of pyelonep&ritic area -".' Most episo%es of uncomplicate% acute pyelonep&ritis occur in normal urinary tracts' +n contrast, a renal or perinep&ric a(scess is, in t!o9t&ir%s of cases, a complication of an anatomic a(normality in t&e urinary tract suc& as esicoureteral reflu1, renal stones, a neurogenic (la%%er, o(structi e tumors, or polycystic ki%ney %isease -2.' 24ee :Urinary tract infection in polycystic ki%ney %isease:3' IAGNOSIS / T&e initial clinical picture of a renal a(scess %ue to ascen%ing infection %oes not fun%amentally %iffer from t&at of uncomplicate% acute pyelonep&ritis' Typical presenting signs an% symptoms inclu%e %ysuria an% fre8uency 2!&ic& are not usually seen !it& &ematogenous sprea%3 follo!e% (y t&e acute onset of fe er, c&ills, unilateral flank pain, an% leukocytosis' T&ere are, &o!e er, t&ree important fin%ings t&at suggest t&at simple acute pyelonep&ritis is not present, ; T&e urinalysis may (e normal an% t&e urine culture may (e negati e if t&e a(scess %oes not communicate !it& t&e collecting system' T&is is more common !it& &ematogenous sprea%, alt&oug& stap&ylococcal (acteriuria is present in some cases -6.' +n comparison, pyuria an% (acteriuria are seen in almost all cases of ascen%ing infection' < en t&oug& t&e me%ullary a(scess may not %irectly communicate !it& t&e collecting system, t&e !&ole ki%ney is pyelonep&ritic resulting in t&e appearance of t&e offen%ing organism in t&e urine' ; Fe er an% leukocytosis persist for more t&an fi e %ays %espite appropriate antimicro(ial t&erapy' +n comparison, acute pyelonep&ritis s&oul% %efer esce !it&in t&ree %ays after t&erapy is (egun'

; =olymicro(ial gro!t& on a noncontaminate% urine culture' T&e lack of s8uamous epit&elial cells on urinalysis of t&e same specimen sent for culture is usually in%icati e of a noncontaminate% specimen' +f t&is !as not %one, %emonstration of polymicro(ial gro!t& on a secon% urine culture may (e necessary' Radiologic e!aluation / >ack of clinical impro ement s&oul% (e follo!e% (y a ra%iologic e1amination, looking for a renal or perirenal a(scess' 24ee :+n%ications for ra%iologic e aluation in acute pyelonep&ritis:3' T&e a(scess can (e seen !it& eac& of t&e ma$or imaging a(normalities, ; An intra enous pyelogram s&oul% s&o! a space9occupying mass 2s&o! ra%iograp& 13' ; 5enal ultrasonograp&y re eals a t&ick9!alle% ca ity fille% !it& flui% 2s&o! ra%iograp& 23' +n some cases, ec&oes %ue to necrotic %e(ris result in a picture %ifficult to %istinguis& from t&at of necrosis !it&in a renal cancer' +f t&e lesion is accessi(le, percutaneous nee%le aspiration may (e performe% to o(tain flui% for ?ram stain an% culture' ; T&e fin%ings on @T scan ary !it& t&e stage of t&e %isease' T&e initial focus is a focal (acterial nep&ritis 2also kno!n as acute lo(ar nep&ronia or focal pyelonep&ritis3 !&ic& is manifeste% (y a focal, mass9like lesion' T&is is follo!e% (y li8uefaction, !&ic& !alls off t&e center of t&e pyelonep&ritic area -".' @T scan re eals t&e typical fin%ings of a renal a(scess in !&ic& a &yper%ense rim of contrast surroun%s t&e !alle%9off a(scess ca ity 2calle% t&e :ring sign:3 2s&o! ra%iograp& )3 -".' ; Alt&oug& not !i%ely use% at present, gallium scanning can also localize a renal a(scess 2s&o! ra%iograp& 63 Ae use ultrasonograp&y or @T scanning to esta(lis& t&e %iagnosis of a renal or perinep&ric a(scess' Bne stu%y of 61 consecuti e patients foun% t&at t&ese proce%ures %etecte% 92 an% 96 percent of a(scesses, respecti ely -1.' TREAT"ENT / =rior to t&erapy, t&e a(scess may continue to gro!, rupture into t&e perinep&ric space, an% %rain (y rupturing into t&e collecting system' T&e t!o ma$or components of treatment are long9term antimicro(ial t&erapy* an% cat&eter %rainage -,62.' Me%ical t&erapy is most effecti e if (egun (efore t&e infection &as sprea% (eyon% t&e renal capsule' 4urgery is re8uire% only in selecte% cases Antimicrobial therap# / T&e c&oice of antimicro(ials %epen%s in part upon t&e stage at !&ic& t&e %iagnosis is ma%e' +f, for e1ample, a patient &as alrea%y (een starte% on an appropriate anti(iotic for presume% cystitis or pyelonep&ritis, t&en t&is agent may (e continue% if aspirate of t&e a(scess re eals t&e same organism or is alrea%y sterile' +n comparison, t!o %rugs are recommen%e% in t&e untreate% patient to more rapi%ly re%uce t&e (acterial inoculum an% possi(ly to minimize t&e emergence of resistant strains' Ae usually (egin !it& an aminoglycosi%e plus ampicillin or a fluoro8uinolone 2suc& as ciproflo1acin or oflo1acin3 if t&e organism is sensiti e to (ot& %rugs' +n general, t&e aminoglycosi%e is gi en for 1# to 16 %ays 2(ut not longer %ue to t&e risks of nep&roto1icity an% ototo1icity3 !&ereas oral ampicillin or t&e fluoro8uinolone is continue% for se eral !eeks' T&e total %uration of antimicro(ial t&erapy is %etermine% (y t&e response' as assesse% in part (y @T scan 2see (elo!3' @&anges in t&e antimicro(ial regimen are necessary in some cases' +n one report, for e1ample, a c&ange !as re8uire% in 1# of )) patients -C.' T&is reflecte% a %ifference (et!een t&e results of urine an% (loo% cultures an% %irect culture of t&e contents of t&e a(scess' Treatment efficacy an% %uration (ase% upon clinical, la(oratory, an% ra%iologic stu%ies' T&e

patient !&o respon%s typically feels (etter !it&in t!o to t&ree %ays an% is afe(rile !it&in one to t!o !eeks' +n comparison, t&e eryt&rocyte se%imentation rate an% @9reacti e protein le el return more slo!ly to!ar% normal' 5epeat ultrasoun% an%Dor @T e1aminations %emonstrate progressi e re%uction in t&e size of t&e a(scess ca ity' T&e total %uration of antimicro(ial t&erapy is %etermine% (y t&e clinical response an% ranges from one to t$o months in most patients' T&e criteria for a(scess cure inclu%e resolution of pain, fe er, an% malaise, normalization of t&e eryt&rocyte se%imentation rate, an% %isappearance of t&e a(scess ca ity on @T scan, !&ic& usually s&o!s a permanent cortical scar' Antimicro(ial t&erapy can (e %iscontinue% !&en t&e clinical an% la(oratory parameters &a e (een sta(le for ten %ays' T&e a(sence of recurring signs an% symptoms of infection an% inflammation after cessation of antimicro(ials is t&e (est in%icator of (acteriologic cure' T&us, t&e patient s&oul% (e monitore% at t!o !eek inter als for t!o to t&ree mont&s after t&e en% of t&erapy' Percutaneous drainage / Alt&oug& many patients !ill respon% to antimicro(ial t&erapy alone -6., !e recommen% insertion of a percutaneous cat&eter into t&e a(scess un%er ultrasoun% or @T gui%ance to o(tain a specimen for culture an% to %rain t&e pus9fille% ca ity in an attempt to &asten reco ery an% s&orten t&e %uration of antimicro(ial t&erapy -1,2,C,9.' +n one stu%y, for e1ample, 7" of 61 renal a(scesses !ere %raine%* all of t&e patients impro e% an% sur i e% -1.' =ercutaneous %rainage is particularly (eneficial !&en t&e a(scess is large 2%iameter of t&ree cm or more3 or !&en surgery is in%icate% in a &ig&9risk patient !&o is not a goo% surgical can%i%ate' Surger# / 4urgical %rainage of a renal or perinep&ric a(scess s&oul% (e consi%ere% !&en t&e a(scess is secon%ary to an anatomic a(normality 2suc& as renal stones or esicoureteral reflu13 or !&en its size an% associate% lesions make it unlikely t&at me%ical treatment alone or !it& cat&eter %rainage !ill (e effecti e' 5escue nep&rectomy is occasionally performe% in patients !it& a complicate% renal a(scess' 4uc& a patient mig&t (e %ia(etic !it& marke% %estruction of renal tissue (y pyelonep&ritis' References 1' Fo!ler, E< Er, =erkins, T' =resentation, %iagnosis an% treatment of renal a(scesses, 19"29 19CC' E Urol 1996* 171,C6"' 2' 0utc&ison, FF, Gaysen, ?A' =erinep&ric a(scess, T&e misse% %iagnosis' Me% @lin Fort& Am 19CC* "2,99)' )' ?ra es, 5@, =arkins, ><' @ar(uncle of t&e ki%ney' E Urol 2Haltimore3 19"#* 1#6,1"9' 6' 0o erman, +I, ?entry, >B, Eones, DA, ?uerriero, A?' +ntrarenal a(scess' 5eport of 16 cases' Arc& +ntern Me% 19C#* 16#,916' 7' 4iroky, MH, Moylan, 5A, Austen, ?, Blsson, @A' Metastatic infection secon%ary to genito9 urinary sepsis' Am E Me% 19"6* 61,)71' 6' >ee, HG, @rossley, G, ?er%ing, DF' T&e association (et!een 4tap&ylococcus aureus, (acteremia an% (acteriuria' Am E Me% 19"C* 67,)#)' "' 0uang, EE, 4ung, EM, @&en, GA, et al' Acute (acterial nep&ritis, A clinicora%iologic correlation (ase% on compute% tomograp&y' Am E Me% 1992* 9),2C9' C' >ang, <G' 5enal, perirenal an% pararenal a(scesses, =ercutaneous %rainage' 5a%iology 199#* 1"6,1#9' 9' Deyoe, >A, @ronan, EE, >am(iase, 5<, Dorfman, ?4' =ercutaneous %rainage of renal an% perirenal a(scesses, 5esults in )# patients' AE5 Am E 5oentgenol 199#* 177,C1'