Bilateral xanthogranulomatous pyelonephritis

Laparoscopic approach for xanthogranulomatous pyelonephritis and pyonephrosis

INTRODUCTION

Xanthogranulomatous pyelonephritis (XGPN) is a rare form of chronic renal inflammation, caused by long-term obstruction of the urinary tract. Pyonephrosis is a severe suppurative complication of acute obstructive pyelonephritis. Although minimally invasive approaches have many advantages, the safe dissection of the kidney may not be always achievable.

MATERIALS AND METHODS

We reviewed 27 cases diagnosed with either XGPN or pyonephrosis, who underwent laparoscopic total nephrectomy between October 2016 and March 2022 in our department. All interventions were performed using the Karl Storz 3D laparoscopic system. The surgical approach was standard transperitoneal nephrectomy for the majority of XGPN, while pyonephrosis cases were carried out in a retroperitoneally. All procedures were performed or supervised by the same surgeon.

RESULTS

The mean operative time was 269.85 minutes (range 145-360). The mean hemoglobin drop after surgery was 1.41 g/dl (range 0.3-2.3 g/dl). Difficult dissection was encountered in 13 cases (48.14%). Nine out of 13 interventions were carried out in a complete intracorporeal fashion, while conversion to open surgery was needed in 4 cases. Vascular complications involving the major blood vessels comprised of one case of inferior vena cava (IVC) tear. Digestive tract-related complications comprised two fistulas of the descending colon and one peritoneal breach. Multiorgan resection was performed in 6 cases.

CONCLUSION

Total nephrectomy in cases of XGPN and pyonephrosis is a challenging procedure. The laparoscopic approach is feasible, as most complications are resolved intracorporeally. However, it may remain reserved for large-volume centers with experienced surgeons.

Atypical Clinical Presentation of Xanthogranulomatous Pyelonephritis in a Female Child: A Case Report

Xanthogranulomatous pyelonephritis (XGPN) is an uncommon chronic obstructive renal suppuration disease. Histopathologically, XGPN manifests as lipid-laden macrophage infiltration in renal microstructure and inflammation of an engorged non-functional kidney. Nephrectomy is the standard therapeutic treatment, and the overall prognosis is good. Here, we report a case of XGPN presented as flank pain in an otherwise healthy child.

Xanthogranulomatous Pyelonephritis With Extension to the Liver: A Case Report

Xanthogranulomatous pyelonephritis (XGP) is an uncommon condition representing 1% of all renal infections. XGP due to complicated pyelonephritis associated with hepatic abscess is an extremely rare complication and has rarely been reported in the literature. We report a rare case of a 54-year-old female with a history of diabetes and recurrent urinary tract infections (UTI) who presented with acute right flank pain and fever which had been ongoing for four days. CT scan showed multiple bilateral obstructive nephrolithiasis associated with a liver abscess. Given the patient's high risk of nephron loss, a bilateral renal and liver abscess drainage followed by a two-stage flexible ureterorenoscopy (FURS) was performed. One week later, a CT scan showed a typical radiological aspect of XGP on the right kidney invading the liver. She urgently underwent a right nephrectomy with an uneventful outcome. In conclusion, the diagnosis of XGP should be considered in the presence of complicated pyelonephritis associated with hepatic abscess.

Xanthogranulomatous Pyelonephritis Caused by Stenotrophomonas maltophilia—The First Case Report and Brief Review

Xanthogranulomatous pyelonephritis (XGP) represents a rare and severe pathology secondary to chronic urinary obstruction and recurrent infections. Commonly, this condition leads to loss of kidney function, and frequently, surgical approach is the only optional treatment. Proteus mirabilis and Escherichia coli are the most frequent pathogens associated with XGP. The actual changes in the pathogen’s characteristics increased the risk of newly acquired infections once considered opportunistic. Stenotrophomonas malthophilia is one of those agents more related to immunocompromised patients, presenting an increased incidence and modified antibiotic resistance profile in the modern era. This case report presents a healthy female patient with an underlying renal stone pathology diagnosed with XGP related to S. maltophilia urinary infection. After a complete biological and imagistic evaluation, the case was treated as pyonephrosis. Empirical antibiotic administration and a surgical approach were considered. A total nephrectomy was performed, but the patient’s condition did not improve. The patient’s status improved when specific antibiotics were administered based on the bacterial identification and antibiotic susceptibility pattern of drained perinephric fluid. Levofloxacin and Vancomycin were considered the optimal combination in this case. The histopathological examination revealed XGP secondary to chronic renal stone. The present study describes the first case of XGP related to an aerobic Gram-negative pathogen such as S. maltophilia, once considered opportunistic, in an apparently healthy female adult.

Case report: Localized xanthogranulomatous pyelonephritis in children: A case report and literature review

BACKGROUND

Xanthogranulomatous pyelonephritis (XGPN), which is featured by inflammatory destruction of renal parenchyma and fibrosis of kidney, occurs mainly among adults, sporadically among children and rarely among infants. Recurrent urinary tract infections, kidney stone-induced obstructive nephropathy, malnutrition, abnormal lipid metabolism, hypoimmunity, lymphatic obstruction and congenital urinary abnormalities may all cause XGPN among children. Its primary treatment is radical nephrectomy.

CASE DESCRIPTION

In this study, we describe a rare case of XGPN in a 7-year-old boy infected with Staphylococcus aureus (S. aureus). The child presented with symptoms including recurrent fever, urine culture negative. The postoperative pathology confirmed XGPN. Besides, partial nephrectomy was performed.

CONCLUSION

XGPN, as a special type of chronic pyelonephritis, is a rare pyelonephritis requiring surgical treatment. Early diagnosis and treatment are crucial to reducing its morbidity and mortality. Although radical nephrectomy is the primary therapeutic option for patients with XGPN, partial nephrectomy surgery should be considered for focal XGPN, aiming to preserve residual renal function in children as far as possible.

Severe Urosepsis Secondary to Xanthogranulomatous Pyelonephritis: A Case Report

Xanthogranulomatous pyelonephritis (XGP) is considered to be a rare variant of chronic pyelonephritis, which results in non-functioning kidneys in patients. The exact etiology of this disease is still unknown, and hence even its pathophysiology remains unclear. We present a case of a 27-year-old Saudi male patient who had been bed-bound with a known case of a congenital anomaly with severe kyphoscoliosis, bilateral lower limbs deformity with paraplegia, and a ventriculoperitoneal shunt since childhood. The patient was brought to the emergency department (ED) with right flank pain associated with fever and difficulty in breathing. The patient had a past medical history of recurrent urinary tract infection (UTI) with up to two incidences per year and renal stones. He had been recently discharged from the ICU of another hospital with sepsis due to UTI. An abdominal CT scan was performed, which showed a mass in the upper lobe of the right kidney measuring about 9 x 8 x 6 cm, suggestive of XGP. The final diagnosis was severe urosepsis secondary to right obstructive pyelonephritis. Patients with XGP usually present with nonspecific symptoms including back and abdominal pain, fever, UTI, and the condition is more common among middle-aged women. Ultimately, early detection and diagnosis, followed by prompt treatment with partial or total nephrectomy are associated witha good prognosis for patients with XGP.

Xanthogranulomatous pyelonephritis in a pediatric patient

Introduction:

Xanthogranulomatous pyelonephritis consists of a chronic infectious and inflammatory process of the renal parenchyma, a variant of chronic obstructive pyelonephritis. It is more prevalent in middle-aged adults, rare in pediatric patients, with less than 300 cases reported in children worldwide.

Report:

Preschooler, aged 2 years and 11 months, male, with 2 months of abdominal distention, increased temperature and intense pallor, associated with microcytic anemia refractory to the use of ferrous sulfate. 1 week before, he had a bulging in his left flank and a hard palpable mass there. Imaging exams (ultrasound and tomography) revealed an overall enlargement of the left kidney, destruction of the renal parenchyma and intense calyceal dilation, forming the "bear's paw" sign, with a staghorn calculus in the pelvis. He underwent treatment with antibiotic therapy and total nephrectomy, with a specimen sent for pathological examination.

Discussion:

a disease of uncertain incidence in the pediatric age group, xanthogranulomatous pyelonephritis is more prevalent in male children and affects mainly the left kidney, being frequently associated with the presence of stones. Clinically, it has nonspecific symptoms, the most common being abdominal distension and asthenia. Laboratory exams shows microcytic, leukocytosis, thrombocytosis and increased inflammation, pyuria, hematuria and proteinuria, in addition to bacterial growth in urine culture. The diagnosis is anatomopathological, but it can be hinted by contrasted CT scan, with the classical sign of the "bear's paw". Treatment may include nephrectomy and broad-spectrum antibiotic therapy.

Clinicopathological Spectrum of Xanthogranulomatous Pyelonephritis

Xanthogranulomatous pyelonephritis (XGP) is an uncommon and distinct type of chronic infective pyelonephritis causing destruction of the kidney, severely affecting the renal function. The perinephric adipose tissue and peritoneum is not uncommonly involved. The study was undertaken to decipher the clinicopathologic spectrum of XGP. Forty cases of XGP were diagnosed on histopathology over a period of 13 years (2005–2017). Relevant clinical details and radiological findings were recorded from the case files. Out of a total of 40 cases, 26 were female and 14 were male with a mean age of 39.5 ± 13.6 years. Flank pain was the most common presenting symptom. All the patients had unilateral disease and underwent nephrectomy for a nonfunctional kidney. Gross examination showed enlarged kidney with replacement of cortico-medullary tissue by yellow nodular areas of fatty tissue and dilatation of the pelvicalyceal system. Thirty-six (90%) cases had nephrolithiasis. Histologically, the characteristic feature was the existence of lipid-laden foamy macrophages. Renal parenchymal involvement was diffuse in majority (31, 77.5%). Two (5.0%) of the patients had coexisting carcinoma in the same kidney. Histopathologic examination gives the definitive diagnosis of XGP which relies on the characteristic morphology. Surgical intervention in the form of nephrectomy is the treatment of choice and offers good treatment outcomes.

Xantogranulomatous pyeloneprhritis in children

Abstract

Xanthogranulomatous pyelonephritis (XPN) is an unusual and severe form of chronic inflammatory lesion of the kidney, characterised by the destruction of the renal parenchyma and the presence of multinucleated giant cells and lipid-laden macrophages, inflammatory infiltration and intensive renal fibrosis. There are a few cases in the literature which describe the disease in children. The pathomechanism of XPN is poorly understood. Renal obstruction with concomitant urinary tract infection is the most commonly associated pathological finding. The process is typically unilateral and may be focal or diffuse. In both cases, the perirenal infiltration is possible and can be mistaken for common renal neoplasm or inflammatory process. The symptoms are non-specific. Diagnostic imaging techniques with clinical suspicion have enabled XPN to be diagnosed and differentiated from malignancy with a high degree of confidence. Computed tomography (CT) is the mainstay of diagnostic imaging. The definitive diagnosis of XPN is based on pathological assessment after nephrectomy. We review and illustrate the clinical, radiological, surgical and pathological characteristics of XPN in children. All cases shown are surgically and histopathologically proven.

Teaching Points

• XPN can present different clinical manifestations.

• CT is the mainstay of diagnostic imaging in XPN.

• Focal type of XPN should be included in the differential diagnosis of children with a renal mass.

• There are no clear guidelines on the management of XPN.

• Conservative and surgical treatments should be considered for each individual case.

• Histopathological examination confirms the diagnosis and excludes other benign and malign diseases.

Early Progression of Xanthogranulomatous Pyelonephritis in Children Might Be Dependent on Vimentin Expression

BACKGROUND Xanthogranulomatous pyelonephritis (XP) is an extremely rare, severe, atypical form of chronic renal parenchymal inflammation accompanied by hydronephrosis and/or urolithiasis. The pathomechanism of XP is not yet fully understood. Microscopically, XP is indicated by the presence of multinucleated giant cells and lipid-laden macrophages, as well as inflammatory infiltration and intensive renal fibrosis. The lipid accumulation in kidney parenchyma may be secondary to the altered flow of low-density lipoprotein (LDL)-derived cholesterol particles inside the affected cells. Physiologically, the process of LDL-derived cholesterol transport from lysosomes to the sites of its esterification is dependent on vimentin, which is a molecule comprising the cytoskeleton in mesenchymal cells. CASE REPORT A 7-year old girl was hospitalized because of the finding of unexplained kidney lesions on an abdominal ultrasound examination (an enlarged and deformed collecting system of the right kidney with hyperechogenic, solid, staghorn lesions in the calyces). Three months earlier, the patient had experienced recurrent urinary tract infection. Based on the subsequent laboratory and imaging diagnostics, the final diagnosis of XP was established and the girl was qualified for right-sided nephrectomy Microscopic examination revealed numerous foci of granuloma formations with no evident exponents of dysplastic or neoplastic abnormalities. Significant CD68-positive cell infiltrations and scattered foam cells arranging the numerous foci of granuloma inflammation were noticed. Renal parenchyma, adjacent to granuloma lesions, presented a vimentin expression. CONCLUSIONS Vimentin expression in XP may confirm a focal character of chronic granuloma formation and may suggest the complexity of XP pathogenesis involving not only macrophage and fibroblast activation but also local lipid deregulation and fibrosis.

Case report: Xanthogranulomutous pyelonephritis presenting as "Wilms' tumor"

Background

Xanthogranulomatous pyelonephritis (XGP) is a rare renal tumor that arises as a complication of chronic obstructive pyelonephritis of uncertain etiology. It is primarily an adult tumor seen occasionally in children associated with urinary tract obstruction due to congenital urological anomalies, nephrolithiasis, and recurrent urinary tract infections. Radiologically, it may show neoplastic features such as those seen in common pediatric renal malignancies like wilms’ tumor and renal cell carcinoma. This overlap in radiological manifestation frequently leads to misdiagnosis and delay in appropriate intervention. We report a case of a 3 years old boy who presented with history of recurrent urinary tract infections and a left renal mass initially thought to be Wilms’ tumor.

Case presentation

We present a case of a 3 years old boy admitted to the Pediatric oncology unit at Muhimbli National Hospital in Dar es Salaam, Tanzania with one year history of recurrent fever and urinary tract infection signs and symptoms refractory to antibiotic therapy. He was eventually found to have a left kidney mass detected at the District hospital by abdominal ultrasound performed to evaluate a flank mass that was felt by his mother. He was then referred to our unit for a suspicion of Wilms’ tumor which finally turned out  to be a left kidney Xanthogranulomatous pyelonephritis.

He underwent a successful left nephrectomy and was discharged from hospital in a stable clinical condition and remains asymptomatic at the time of submission of this case report.

Conclusion

This case report underscores the need for clinicians attending a febrile child with a renal mass that can be confused with common pediatric renal malignancies such as Wilms’ tumor to broaden their differential diagnosis. The case also underlines the significance of individualized patient evaluation because this patient would have otherwise received preoperative chemotherapy under the International Society of Pediatric Oncology (SIOP) guidelines if the diagnosis of Wilms tumor was not ruled out.

Xanthogranulomatous pyelonephritis presenting as a pseudotumour

INTRODUCTION

Xanthogranulomatous pyelonephritis (XGPN) is an atypical form of chronic pyelonephritis referred to as the "great imitator" because the clinical and radiological findings closely resemble other pathological entities, especially for the focal forms. Distinguishing focal XGPN from renal cancer is preoperatively difficult.

METHODS

We report a total number of 12 pseudotumoural XGPN cases diagnosed and treated in our department. The aim of this study is to try to better understand the clinicopathological profile of XGPN and improve its management.

RESULTS

The mean age of patients was 51.52 years. Gender ratio was 0.71. An obstructive renal calculus was noticed in nine patients (75%). Only one patient (8.3 %) presented with loin pain associated with fever, weight loss, asthenia, and increased biological inflammation markers. A bifocal mass was noticed in one case (8.3 %). The average size of the tumour was 6.58 cm. The mass was cystic in three cases (25 %). Perinephral fat strand, thickening of Gerota's fascia, hydronephrosis, and presence of renal calculi was noticed in all solid tumour cases. XGPN was suspected in only one case (8.3%), a percutaneous biopsy showed XGPN lesions treated by antibiotics and a double J drainage. Radical nephrectomy was performed in eight patients (66.7 %) and three patients underwent partial nephrectomy (25 %). No recurrence of XGPN has been noted.

CONCLUSION

Pseudotumoural XGPN is a rare benign disease of the kidney. Its treatment should be conservative. Lack of knowledge of this disease may explain the high rate of abusive nephrectomies. These data should be considered in the future.

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Nous présentons l’observation clinique d’un cas rare de pyélonéphrite xanthogranulomateuse (PXG) bilatérale chez un jeune patient âgé de 17 ans. La découverte progressive de l’infection a débuté par l’apparition de lombalgies bilatérales évoluant depuis un mois, sans autre signe associé. L’urotomodensitométrie penchait en faveur de deux masses rénales bilatérales, soit une masse polaire inférieure droite et une masse polaire supérieure gauche, toutes deux de densité tissulaire. Une biopsie écho guidée a suggéré la présence d’une réaction inflammatoire non spécifique. Une néphrectomie partielle polaire inférieure droite a été effectuée devant la forte présomption de tumeurs rénales malignes. Finalement, l’histologie a orienté le diagnostic vers une PXG. Il s’agit, à notre connaissance, du sixième cas de PXG focale bilatérale rapporté dans la littérature. Notre patient a reçu un traitement antibiotique à base de fluoroquinolone pendant un mois. L’évolution clinique s’est avérée bonne, et les lésions visibles à la tomodensitométrie se sont entièrement résorbées au bout d’un mois. Le patient vit toujours après un an et présente une fonction rénale normale.

Xanthogranulomatous Pyelonephritis: Unusual Clinical Presentation: A Case Report with Literature Review

Xanthogranulomatous pyelonephritis (XGP) is rare and aggressive form of chronic infectious pyelonephritis. No single clinical or radiological feature is diagnostic of XGP. A 75-year-old man with prostatic enlargement presented with difficulty and burning micturition fever, abdominal and flank pain. X-ray, ultrasonography and computed tomography scan diagnosis was right kidney pyonephrosis. Intravenous urography revealed non-excretory right kidney. Right nephrectomy was done. Histological diagnosis of XGP was made. In all patients of prostatic enlargement, renal function must be assessed for the extent of damage. Surgery is the treatment choice in most cases. Pre- and post-operative antibiotics are key factors for successful management and better prognosis.

Xanthogranulomatous pyelonephritis

Xanthogranulomatous pyelonephritis is an uncommon chronic destructive granulomatous process of renal parenchyma in association with long-term urinary tract obstruction and infection. It affects females more often than males, with a wide range of age, from newborn to elderly. Almost all patients are symptomatic and the most common symptoms are flank or abdominal pain, lower urinary tract symptoms, fever, palpable mass, gross hematuria, and weight loss. The common laboratory findings are leukocytosis and anemia. Urine cultures most often reveal Escherichia coli and Proteus mirabilis . Computed tomography is the mainstay of diagnostic imaging for xanthogranulomatous pyelonephritis. Imaging studies may demonstrate diffuse or focal form. Histologically, xanthogranulomatous pyelonephritis presents a granulomatous inflammatory infiltrate composed of neutrophils, lymphocytes, plasma cells, xanthomatous histiocytes, and multinucleated giant cells. The differential diagnosis includes clear cell renal cell carcinoma, papillary renal cell carcinoma, sarcomatoid renal cell carcinoma, leiomyosarcoma, malakoplakia, and megalocytic interstitial nephritis. Both antibiotics and surgery can be treatment options depending on the patient's disease status.

Xanthogranulomatous pyelonephritis in pediatric patients: case report and review of literature

Xanthogranulomatous pyelonephritis (XPN) is an unusual and rare form of chronic renal suppuration. XPN is often mistaken for renal malignancy; hence nephrectomy is commonly performed and the diagnosis confirmed by histopathology. Recent advances in imaging have allowed the radiological features to be characterized, such that routine nephrectomy is avoided. Approximately 240 cases of XPN have been reported in children. We report a 17-year-old female who presented with a 2-month history of increasing abdominal pain and intermittent episodes of increased frequency and dysuria. Plain antero-posterior radiograph of the abdomen revealed a left staghorn calculus. Computed tomography scan with intravenous contrast revealed a low-density inflammatory area and reduced cortical dye uptake on the left renal parenchyma as compared to the opposite side. A dimercapto-succinic acid renal scan revealed that the affected kidney contributed 18% of differential function. A diagnosis of XPN was made. The patient underwent percutaneous nephrostomy tube placement in an attempt to salvage the kidney. The patient eventually failed conservative management. Our review of the literature suggests that medical management has worked in some focal XPN cases, but has not been sufficiently tested in diffuse XPN.