Spontaneous intraperitoneal rupture of pyonephrosis in a patient with unknown kidney carcinosarcoma: a case report

Generalized peritonitis secondary to a renal forniceal rupture in an obstructed pelvic kidney - A case report

Peritoneal fistulization of pyonephrosis is an uncommon condition, leading to a generalized peritonitis, considered as extreme life-threatening emergency. Secondary to an obstructive uropathy, increasing intra-renal pressure. In most cases, ureteral stones represent the underlying causes followed by stenosis, tumor, or connective tissue disease. Through this case report, we present a 60-year-old patient with a history of urolithiasis, admitted for an atypical instance of spontaneous renal pelvis rupture in an ectopic right kidney managed surgically. This case emphasizes the importance of considering renal etiology in cases of peritonitis and underscores the rarity of such occurrences.

Minimal invasive management of generalized peritonitis as a result of spontaneous ureteral rupture

INTRODUCTION AND IMPORTANCE

Generalized peritonitis following proximal ureteral rupture is a very rare complication. This is about a successfully managed case without open surgical intervention.

CASE PRESENTATION

A lady in her 70s presented with generalized abdominal pain, high spiking fever and low urine output for 3 days. She was haemodynamically unstable on admission and was resuscitated and managed at intensive care unit. CECT abdomen revealed partial anterior ureteral rupture with pyonephrosis. She was managed with percutaneous nephrostomy and subsequent anterograde stenting. Her recovery was uneventful and follow up imaging revealed no features of malignancy.

CLINICAL DISCUSSION

Generalized peritonitis due to renal pathology is very rare and it can be due to urolithiasis or neoplasm. Retroperitoneal infections may lead to irritation of peritoneum or fistulation into the peritoneum leading to generalized peritonitis. This can be managed by various surgical and non-surgical management modalities.

CONCLUSION

There are various pathological causes for acute abdomen. One of the rare causes is spontaneous rupture of ureter in pyonephrotic kidney which can also be managed successfully with minimal intervention.

Spontaneous rupture of pyonephrosis presenting as anterior abdominal wall abscess: a rare case report

Background

A pyonephrosis caused by an obstructing calculus is typically accompanied by fever, loin pain, and other signs of urinary tract infection. Occasionally, severe thinning of the renal parenchyma in pyonephrosis allows direct forniceal rupture into the retroperitoneum and very rarely into the anterior abdominal wall, misconstruing it as an isolated abdominal wall abscess.

Case presentation

Diabetes-related 55-year-old diabetic male presented with abscess in his periumbilical region extending into right lumbar region. He did not exhibit any urinary symptoms, and contrast enhanced computed tomography [CECT] abdominal and pelvic examinations revealed right pelvic calculus with pyonephrosis. There is a 7.5 mm defect in the lower pole of the right kidney with 171 cc of collection adjacent to the kidney communicating with 150 cc of superficial abdominal wall collection through a 15 mm defect. Incision and drainage of abdominal and retroperitoneal abscesses were done at first. Right DJ stenting was performed. Right lateral decubitus was placed for dependent drainage. Resolution of residual collections was confirmed by subsequent ultrasonography KUB, and drain was then removed. Right DJ stenting done, and patient was discharged. Two months later, DTPA scan done and revealed GFR of 30 ml/min of right kidney. Patient underwent right percutaneous nephrolithotomy.

Conclusion

The sudden rupture of pyonephrosis is a rare event. Even rarer is the presentation of pyonephrosis as an abscess on the anterior abdominal wall. The correct diagnosis and search for the source of the abscess must be undertaken before intervention. An aggressive and prompt management is needed to prevent further complications from occurring. This case is being presented to add to the literature with regard to abnormal presentations of ruptured pyonephrosis and its management.

Pleural empyema secondary to nephropleural fistula in complicated pyonephrosis

Pleural empyema of extra pulmonary origin is uncommon and empyema secondary to a fistula between the urinary tract and thorax is extremely rare. We report a case of nephropleural fistula causing massive pleural empyema in a 64-year-old woman with a long history of urological problems, including nephrolitiasis and urinary tract infection. She was admitted with sepsis, fever, chills, tachypnea, productive cough and pyuria. At clinical examination, breath sounds were reduced over the left hemithorax. CT revealed a fistulous connection from the upper left calyceal group and the pleural space. Drainage of thoracic and perinephric collection was carried out, but nephrectomy and pleural decortication were required due to haemopurulent urine and decreased hemoglobin levels during the hospitalization. This case demonstrates the unusual and prolonged evolution of an obstructive hydroureteronephrosis complicated by pyonephrosis, culminating in retroperitoneal abscess that fistulized into the pleural space, leading to empyema.

Pyonephrosis Ultrasound and Computed Tomography Features: A Pictorial Review

Urinary tract infections (UTIs) are the most frequent community-acquired and healthcare-associated bacterial infections. UTIs are heterogeneous and range from rather benign, uncomplicated infections to complicated UTIs (cUTIs), pyelonephritis and severe urosepsis, depending mostly on the host response. Ultrasound and computed tomography represent the imaging processes of choice in the diagnosis and staging of the pathology in emergency settings. The aim of this study is to describe the common ultrasound (US) and computed tomography (CT) features of pyonephrosis. US can make the diagnosis, demonstrating echogenic debris, fluid/fluid levels, and air in the collecting system. Although the diagnosis appears to be easily made with US, CT is necessary in non-diagnostic US examinations to confirm the diagnosis, to demonstrate the cause and moreover to stage the pathology, defining extrarenal complications. In emergency settings, US and CT are differently used in the diagnosis and staging of pyonephrosis.

Pyonephrosis by Prevotella disiens and Escherichia coli coinfection and secondary peritonitis in an obstructive uropathy patient: A case report and review of the literature

Pyonephrosis is an uncommon condition that is associated with suppurative destruction of the renal parenchyma. Upper urinary tract obstruction by renal stones plays an important role in its aetiology. The majority of pyonephrosis is reported to be caused by aerobic bacteria but the role of anaerobes, especially black-pigmented gram-negative anaerobes, namely, Prevotella and Porphyromonas in renal infections, remain poorly defined. In view of the rarity of the event, a case of pyonephrosis by Prevotella disiens and Escherichia coli coinfection complicated by secondary peritonitis in an obstructive uropathy patient is hereby presented. An attempt is being made to review the literature on the infective aetiologies of renal abscess with special reference to anaerobes.

Biphasic malignant tumours of the abdominal cavity

Carcinosarcomas (CS) are uncommon, highly aggressive, biphasic tumours consisting of both sarcomatous and carcinomatous elements. They appear to originate from a common cell of origin, either via transformation from a single premature precursor or conversion of a mature epithelial cell through an epithelial-mesenchymal transition. CS should be considered a unique cancer subtype with cells typically displaying diffuse mitotic activity and widespread atypical mitoses predisposing to early metastasis and a tendency to local recurrence following resection. This review addresses the pathophysiology of CS and discusses its presentation, natural history and management at a variety of sites within the abdominal cavity and retroperitoneum.

Multiple carcinosarcomas of the kidney: A case report and review of the literature

Carcinosarcomas are biphasic tumors comprising epithelial and mesenchymal components. Primary carcinosarcoma of the kidney is extremely uncommon and accounts for <1% of all malignant renal tumors. Primary carcinosarcoma of the kidney generally occurs after the age of 60 and the majority of the patients are men. This is the case report of a 56-year-old male patient who presented with left flank pain. Ultrasonography and computed tomography (CT) revealed ureterohydronephrosis and a left distal ureteral stone (25 mm). Renal scan with diethylenetriamine pentaacetate and dimercaptosuccinic acid revealed a non-functional kidney and a left nephroureterectomy was performed. The pathological examination of the surgical specimen revealed high-grade multiple carcinosarcomas according to the Union for International Cancer Control and cancer staging according to the tumor-node-metastasis classification determined the disease as stage T3aN0M0. At 6 months, the patient was administered systemic adjuvant chemotherapy (CTx) due to widespread lung and liver metastases on ¹⁸F-fluorodeoxyglucose positron-emission tomography/CT. However, no response was achieved with systemic CTx. The precise histogenesis of this type of cancer has not been determined. Carcinosarcoma of the kidney is a biphasic tumor and its biphasic nature must be confirmed using immunohistochemical methods during pathological diagnosis. The mesenchymal components of sarcomatoid carcinomas must be verified by pathological examination. Metaplastic changes may have malignant potential but should not be considered as malignant lesions. The most significant histopathological parameter that supports the diagnosis of sarcomatoid carcinoma is the identification of transitional zones between the epithelial and mesenchymal cells. Carcinosarcoma is characterized by aggressive malignant potential and a poor prognosis. An effective curative method has not yet been established, with the exception of radical surgery. It is therefore recommended to perform efficient surgical excision with adequate surgical margins.

Ruptured renal calyx mimicking leaking abdominal aortic aneurysm

The case of an 81-year-old man with a known 5.2 cm abdominal aortic aneurysm (AAA) and transitional cell carcinoma of the bladder who presented to the emergency department in painful clot retention is described. Approximately 5 h after starting bladder irrigation he developed a sudden onset of severe abdominal pain radiating to his back. Urgent CT scan (AAA protocol) revealed a rupture of the lower pole calyx of his right kidney and a stable aneurysm. Bladder irrigation was stopped and the patient settled with a catheter and simple analgesia. Given his significant co-morbidities, it was felt that surgical intervention for the underlying malignancy was inappropriate and the patient was discharged home. At last outpatient review, his renal function was at its baseline and he was suffering no ill-effects from the ruptured kidney.