[Difficulties and errors in the diagnosis and treatment of acute paranephritis in surgical practice]

The authors share their experience with the treatment of 161 patients operated on for purulent paranephritis. Causes of the greater incidence of purulent paranephritis and features of their clinical course are analysed. High diagnostic value of ultrasonography is shown. In order to render the aid in due time the authors propose to operate on the patients within the first hours after making diagnosis.

Acute focal bacterial nephritis

In the kidney, acute focal parenchymal infection without liquefaction can produce a 'mass lesion' that may mimic an abscess or tumour, both clinically and radiologically. Ultrasound and computed tomography can differentiate between these lesions and allow appropriate antibiotic treatment to be used safely, avoiding unnecessary surgical intervention.

Sonographic appearance of cytomegalovirus nephritis in a neonate

In adults and children increased renal cortical echogenicity on ultrasound examination is now well recognized as a feature of renal parenchymal disease due to a variety of etiologies. The degree of echogenicity appears related to the severity of the renal disease, histologically. The sonographic renal pattern of the neonate and in particular, of the premature, differs generally from that of the adult in that the renal cortex of the very young may be "normally" more echogenic than in later life. Marked cortical echogenicity however, is a sign of renal parenchymal disease even in the premature, as illustrated in the case that follows with documented cytomegalovirus nephritis.

Sonographic signs of nephritis in children. A comparison of renal echography with clinical evaluation, laboratory data and biopsy

In 40 children with histologically confirmed diagnosis of nephritis 82 sonographic examinations were performed for evaluation of echographic signs of nephritis. Increased cortical renal echointensity in comparison with the normal liver and enlarged parenchymal volume proved to be the most specific and reliable signs of nephritis, particularly if both were present. Accentuated corticomedullary differentiation was too insensitive to be of additional value. Twenty-one patients had follow up examinations in the course of their nephritis. In 15 patients sonographic signs, serum creatinine and clinical classification showed parallel changes. In two cases sonographic improvement preceded clinical and laboratory normalization by several weeks, giving valuable prognostic information.

Ultrasonographic findings in renal parenchymal diseases

An analysis was made of the ultrasonographic findings in 112 patients with renal parenchymal disease verified histologically, or with an unambiguous clinical picture. The diseases were divided into glomerular and tubulo-interstitial types. The duration of the disease and renal insufficiency and, in cases of glomerular diseases, the presence of a nephrotic syndrome and the severity of the histological changes were also taken into account. An abnormal sonographic finding was recorded in 67% of the cases. A highly echogenic cortex was the most common abnormality, being slightly more frequent in the tubulo-interstitial diseases (75%) than in the glomerular ones (61%), but the difference was not significant. Changes in the medullary region were significantly more frequent in tubulo-interstitial cases (46%) than in glomerular ones, and significantly more frequent in acute than in chronic conditions. Parenchymal thinning was associated with chronic cases and thickening with acute tubulo-interstitial cases. The nephrotic syndrome increased the number of abnormal sonographic findings. No specific sonographic features could be established for either glomerular or tubulo-interstitial renal diseases.

Urinary alanine aminopeptidase activity in various urinary tract diseases

The value of assaying urinary alanine aminopeptidase activity was examined. The activity of normal urine was below 2 IU/1. High urinary alanine aminopeptidase was found to suggest the presence of nephritis, pyelonephritis, or other nephrotoxic processes.

Focal renal masses: magnetic resonance imaging

Thirty patients with focal renal masses were evaluated on a .12-Tesla resistive magnetic resonance unit using partial saturation and spin echo pulse sequences. A short repetition time (TR = 143 ms) was employed for partial saturation images and a spin echo was present in each case (TE = 10 ms). Additional pulse sequences through regions of interest were also obtained. Fifteen patients had cystic lesions, nine patients had renal cell carcinoma, two had metastatic lesions, one had an angiomyolipoma, and three had focal bacterial infection. Cystic lesions were well circumscribed and demonstrated a range of signal intensities. Small intra-parenchymal cysts were difficult to identify. Renal cell carcinomas demonstrated areas of increased signal using a partial saturation sequence (TR = 143-415 ms, TE = 10 ms). Magnetic resonance imaging accurately detected perinephric extension and vascular invasion in all patients. Metastatic disease to the kidney was uniformly low in signal, in contrast to primary renal cell carcinoma; an angiomyolipoma demonstrated very high signal intensity. Two masses resulting from acute focal bacterial nephritis were uniformly low in signal. One additional case of a more indolent pyelonephritis demonstrated high signal in regions of replacement lipomatosis and low signal in sites of active infection. Magnetic resonance imaging appears to be an accurate way of detecting, identifying, and staging focal renal masses.

Sonography of systemic lupus nephritis

Renal sonography was compared with commonly obtained laboratory and pathologic data in 31 patients with systemic lupus erythematosus. Sonography was 95% sensitive in the detection of lupus nephritis, with the major abnormalities being abnormal renal size and cortical echogenicity. Sonography was useful in locating the kidneys for biopsy and in excluding hydronephrosis. However, in the overall evaluation of patients with uncomplicated lupus nephritis, sonography added little information not readily available from laboratory data.

[Perinephretic phlegmon of pseudotumor form]

The authors report a case of perinephric phlegmon simulating a tumor. Ultrasound and CT scan were unable to provide grounds for correct diagnosis. It was only after incision of the mass and drainage of the purulent matter that a correct diagnosis could be made.

Current concepts in the management of urinary tract infections in adults

This article discusses the pathogenesis, etiology, and diagnosis of bacterial urinary tract infections. Initial therapy is outlined, as is the treatment of recurrent infections.

[Infectious mononucleosis (Pfeiffer glandular fever) with membranous angina, nephritis, myocarditis and Guillain-Barré syndrome]

In a 10 year old boy with infectious mononucleosis beginning with membranous tonsillitis, followed by nephritis, myocarditis and Guillain-Barré-Syndrome, all the complications could be managed by symptomatic treatment. With favourable outcome after about 3 months of hospitalisation, he could be discharged with only mild neurologic residuals.

Systemic lupus erythematosus in males

A study of 51 males being followed in the Wellesley Hospital Toronto SLE Clinic examined the questions of whether SLE in males was similar to that in females and whether affected males differ from unaffected males with respect to their maleness and sex hormone profile. Fifty of the men were phenotypically males, and one was known to have Klinefelter syndrome (karyotype 47 XXY). All had four or more 1982 revised criteria for SLE. Fifty females matched with respect to age and duration of disease were used as controls. In examining the spectrum of the disease, 21 clinical and laboratory manifestations were assessed. Although neurologic involvement, alopecia, and thrombocytopenia were less common and pleuritis more common in the males, none of these was statistically significant. Comparison of disease severity revealed only one statistically significant difference: the mean duration of corticosteroid usage was longer in the females. There was also a tendency for cytotoxic agents to be used more frequently in the females. It was thus concluded that spectrum and severity of the disease tended to be similar in males and females. The frequency of positive family histories for SLE and other autoimmune diseases was similar in males and females. The age of onset tended to be more evenly distributed in males than in females, with one quarter of the males diagnosed after the age of 50. HLA typing revealed increased frequencies of the B8 and DR3 antigens in the SLE males compared with normal controls, as had previously also been shown for SLE populations with a female preponderance.(ABSTRACT TRUNCATED AT 250 WORDS)

Interventional ultrasound in detection and treatment of renal inflammatory disease

Fifty-one patients with acute inflammatory renal disease were examined with ultrasound. The spectrum of findings seen in acute pyelonephritis is described, with emphasis on the evolution of the disease from acute focal inflammation to perinephric extension. There were 26 cases of acute bacterial nephritis, 15 cases of abscess formation, and 10 cases of pyohydronephrosis. Pathologic correlation was obtained. The impact of percutaneous needle puncture on the diagnosis and treatment of all stages of renal disease is discussed. Prompt diagnosis can be made, and specific antibiotic therapy can be instituted on the basis of information obtained by ultrasound examination and percutaneous aspiration. If necessary, treatment may be aided by ultrasonically guided placement of drainage catheters. Serial examination will show resolution of the disease, and it avoids exposure of the patient to ionizing radiation and intravenous contrast agents.

[Etiology, clinical manifestations and prognosis of radiation nephritis]

If the irradiation field of a megavoltage therapy extends over one kidney or a part of it, blood pressure reactions suggest in some cases an affection of the kidney. These reactions may already occur after doses of 5 to 20 Gy. After higher doses, a number of symptoms may appear which have been classified into three clinical groups by Sarre and Moser and even into five groups by Luxton and Kunkler. They show histologic manifestations in the glomeruli and tubuli and are mostly progressive. In case of radiotherapy alone, the threshold doses are 20 to 25 Gy. After a latent time of several months, these patients may present renal insufficiency and hypertonia, leading eventually to death in an acute stage, chronic development with preponderant renal insufficiency, hypertonia, or incomplete healing. These doses are considerably lower in children. It has been proved recently that these threshold doses are considerably reduced by combined chemotherapy, too even if the cytostatic drugs alone have no nephrotoxic potential. This is verified by our experimentations on animals. If only a little part of the kidney is situated within the irradiation field, e.g. the upper renal pole in case of an irradiation of the spleen, a significantly reduced activity in the upper pole of the left kidney can be proved by scintigraphy after a period of eight months. After about 18 months, tomography shows a cortical atrophia in this region. However, as far as clinical or technical examinations are concerned, no abnormal parameters could be found.