[Encrusted Pyelitis during a case of Thrombotic Thrombocytopenic Purpura]

Encrusted pyelitis is a chronic urinary tract infection associated with mucosal encrustation induced by urea splitting bacteria. More than 40 bacteria have been implicated but the most frequent is Corynebacterium group D2. Predisposing factors are debilitating chronic diseases and preexisting urological procedures. Immunosoppression is an important cofactor. For these reasons the disease is almost always nosocomially acquired and renal transplant recipients are at particular risk. The symptoms are not specific and long lasting: dysuria, flank pain and gross haematuria are the most frequent; fever is present in two-thirds. The demonstration of urine splitting bacteria in constantly alkaline urines and radiological evidence of extensive calcification of pelvicalyceal system, ureter and bladder at US or CT scan in a clinical context of predisposing factors are the mainstay of diagnosis. Treatment is based on adapted antibiotic therapy, acidification of urine and excision of plaques of calcified encrustation. The prognosis relies on timing of diagnosis; delay can be detrimental and result in patient's death and graft loss. We describe a unique case of 69-year-old man with two contemporary diseases: autoimmune thrombotic thrombocytopenic purpura and encrusted pyelitis with a fatal evolution.

Granulomatous pyelitis associated with urinary obstruction: a comprehensive clinicopathologic study

Urinary obstruction is rarely associated with a distinct granulomatous inflammation, which involves the pyelocalyceal system and closely simulates infectious conditions including tuberculosis. Its clinicopathologic features, however, have not been adequately studied since there are only seven isolated reported cases. In a comprehensive study of 112 kidney specimens with urinary obstruction, we identified five cases of granulomatous pyelitis. The features of these cases were detailed and compared with the previously reported cases. Among the five identified subjects, three patients had history of urolithiasis and two had ureteral stenosis and all had stent placement 7 weeks to 12 years before nephrectomy for relief of the unilateral urinary obstruction. The age distribution was between 38 and 81 years. Two had end-stage renal disease or chronic renal failure. The pyelocaliceal system showed frank hydronephrosis (1 case) or partial dilatation (4 cases) and contained cheesy and gritty material in its lumen. Each case showed severe granulomatous inflammation, which was limited to the pelvic wall and closely associated with calcified debris, necrotic inflammatory cells, and material consistent with Tamm-Horsfall protein. The kidney showed chronic tubulointerstitial nephritis but without granulomas. Cultures of urine, blood, and the renal pelvic content, and special stains of tissue sections did not show fungi or mycobacteria in any case. Many of these features were also observed in previously reported cases. Granulomatous pyelitis is a rare but distinct cliniocopathologic entity characterized by severe noninfectious granulomatous inflammation limited to the renal pelvis, which is uniformely asociated with urinary obstruction and pyelocalyceal dilatation and may develop in response to accumulated calcified material in the renal pelvis. Awareness of this entity and its characteristic clinicopathologic features also helps eliminate an infectious etiology with obvious treatment and prognostic implications.

Renal pelvic wall thickening in childhood urinary tract infections--evidence of acute pyelitis or vesicoureteral reflux?

OBJECTIVE

The aim of this study was to determine whether renal pelvic wall thickening in active childhood urinary tract infections (UTIs), as demonstrated using ultrasound, is caused by acute pyelitis or by vesicoureteral reflux (VUR)-related chronic changes.

MATERIAL AND METHODS

A total of 41 children with at least unilateral renal pelvic wall thickening as demonstrated using ultrasound during the acute stage of UTI, and confirmed using voiding cystourethrography (VCUG), were analyzed. All cases underwent ultrasound studies at 6 months follow-up.

RESULTS

Using ultrasound, 50 halves of the pelvis showed renal pelvic wall thickening. In 27 (54%), ipsilateral VUR could be demonstrated using VCUG. The sensitivity, specificity and positive predictive value of renal pelvic wall thickening for predicting ipsilateral VUR were 79.4%, 52.1% and 54%, respectively. Only 2 (7%) cases presented with wall thickening at 6 months follow-up. Most of the thickening recovered after clinical improvement, although VUR became persistent in half the cases.

CONCLUSIONS

Renal pelvic wall thickening is an abnormal finding in the acute stage of childhood UTI and predominantly indicates acute pyelitis rather than VUR-related chronic changes. Renal pelvic wall thickening is not sufficiently predictive of VUR in acute UTI, although it does provide evidence of upper UTI.

Emphysematous pyelitis presenting as an acute abdomen in an end-stage renal disease patient treated with peritoneal dialysis

Emphysematous pyelitis is air in the renal collecting system in patients with urinary tract infections. This entity is uncommon and seen primarily in patients with diabetes mellitus. We report a case of a patient with end-stage renal disease treated with peritoneal dialysis who developed emphysematous pyelitis who presented with signs and symptoms that were more consistent with appendicitis. The spectrum of infections causing air in the urinary tract and the method by which end-stage renal disease patients are treated are discussed. Patients receiving dextrose peritoneal dialysis are at risk for emphysematous pyelonephritis, pyelitis, and cystitis.

[Multivisceral Kaposi's disease and encrusted pyelitis in a renal transplantation recipient]

Immunosuppression therapy carries inherent risks involving the occurrence of infections and neoplasms. Whereas therapeutic advancement have reduced its frequency, encrusted pyelitis reappears in kidney-transplanted patients and may lead to detransplantation. It is related to chronic urological infections and not inevitably favored by endoscopic explorations. Kaposi's sarcoma is the third cause of tumor in renal-transplanted patients. It is rarely multivisceral and develops exceptionally in the transplant. We report the case of a 60 year-old woman who developed an encrusted pyelitis and a Kaposi's sarcoma in a kidney which was transplanted 14 months earlier.

Obliterative pyeloureteritis: a complication of stone disease in patients with urinary conduit diversion

In 4 patients with cutaneous urinary diversion who underwent percutaneous ureteral stone removal, similar ureteral complications developed as a result of severe ureteritis at the site of the stone. Ureteral narrowing occurred within days of percutaneous ureteral stone removal, progressing to complete occlusion in 2 cases. These complications led to prolonged hospitalization and additional procedures for each patient. One patient with an occluded ureter was lost to followup. Two patients responded satisfactorily to repeated ureteral dilations and prolonged stenting. One patient underwent excision of the affected ureteral segment. The average interval between tube placement and removal of tubes and stents was 15 weeks in 4 patients. The average inpatient period was 24 days. Patients with a cutaneous urinary conduit diversion may be at increased risk for complications following percutaneous treatment of ureteral stones. This risk may be secondary to an intense inflammatory response due to infection and other local factors.

Chronic follicular pyeloureteritis

A case of chronic follicular pyeloureteritis is presented. This rare lesion, not previously published in the American literature, must be differentiated from primary renal lymphoma and generalized malignant lymphoma of the nonHodgkin type.

US demonstration of pyelitis and ureteritis in children

The authors report a new ultrasonic sign of urinary tract infection in children: thickening of the renal pelvis and/or ureteral wall. This thickening as encountered in 10 children, (10 months to 12 years) all with urinary tract infection, appears to result from inflammatory changes and to correspond to a sonographic sign of pyelitis and ureteritis. These alterations of the walls are similar to striations and folds described in this pathology on intravenous pyelograms. The thickening was the only sign of abnormality of the urinary tract in two cases; it was observed without reflux in four cases. The demonstration of this pattern should lead to further uroradiological investigations and to appropriate treatment.

Emphysematous renal and perirenal infection in nondiabetic patient

Emphysematous renal infection is a severe, rare complication of urinary tract infection associated with gas production, which frequently causes renal destruction and has a high mortality rate. It is termed emphysematous pyelitis when gas is confined to the collecting system, or emphysematous pyelonephritis if it also involves the parenchyma with or without the perirenal space. Only 7 cases of perirenal emphysema have been described previously; all were in diabetics. Here we present a rare case of gas-producing renal infection in the collecting system and perirenal tissues, in a nondiabetic patient, and discuss the management of the various types of emphysematous renal infections.

Klebsiella pneumoniae-induced experimental pyelitis: the effect of piliation on infectivity

The effect of bacterial piliation on the infectivity of Klebsiella pneumoniae in the renal pelvis was examined by means of piliated and nonpiliated variants derived from a single parent strain. Piliated-phase variants were significantly more infective as determined by viable counts of bacteria isolated from the kidneys at the time of sacrifice. In addition, scanning electron microscope was used to examine the renal pelvis for evidence of infection. Kidneys infected with piliated-phase organisms exhibited greater tissue damage -- both in the magnitude of tissue alterations observed and in the number of kidneys affected. Thus, it is concluded that piliation contributes to the ability of K. pneumoniae to infect the renal pelvis following reflux from the bladder.

[Cystic pyeloureteritis. Presentation of 10 cases]

Based on the analysis of 10 cases of cystic pyeloureteritis, a rare entity of benign outcome, the authors suggest that the cysts might be the result of an hyperreactivity of the urothelium to an aggression, and feel that the correction of the etiologic factors might prevent the evolution of Von Brunn's nests.

Renal infection in the rat after reflux challenge with Pseudomonas aeruginosa

A rat-pseudomonad reflux model was employed to examine the effect of the size of inoculum on the emergence of renal infection. Widely varying degrees of renal disease observed in challenged animals indicated that a number of variables influenced the outcome of the host-parasite interaction. In this regard, animals in which there was a reduction of the colony counts below a threshold figure rarely gave evidence of renal infection when examined at autopsy on the eighth day following reflux. These results suggest that a threshold level of bacteriuria may also have to be exceeded if renal infection is to become established in patients with vesico-ureteric reflux.

[Carcinoma of the bladder in childhood (author's transl)]

The authors describe the extremely rare finding of a keratinized squamous cell carcinoma of the bladder in a 13 year old girl without however a history of the typical symptoms of the illness such as hematuria. The findings are reviewed in the light of the current literature. Enuresis leading to a chronic infection of the urinary tract is discussed as the possible etiologic factor.

Pyelo-ureteritis cystica associated with a urinary tract infection due to a coagulase-negative staphylococcus

A young female presenting with a history suggestive of renal colic was found by intravenous pyelography to have Pyeloureteritis Cystica. In association with this condition she had a urinary tract infection due to a coagulase-negative staphylococcus. Following a two week course of appropriate antibiotic therapy, her urine became sterile and repeat pyelography revealed no abnormality.

Urinary diversion: the physiological rationale for non-refluxing colonic conduits

In order to make an accurate comparison between ileal and colonic conduits, and ileal conduit was created from one kidney and a non-refluxing colonic conduit from the other kidney in 16 adult mongrel dogs. Colonic loops do not reflux, have equal resting pressures and rate of emptying when contrasted with ileal conduits, and carry a lower incidence of stomal complications. Colonic conduits respond more favourably to acute occlusion and produce a significantly lower rate of pyelonephritis at 3 months. These factors suggest that colonic conduits offer a definite advantage for long-term urinary diversion.