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Year : 2006  |  Volume : 16  |  Issue : 2  |  Page : 243-245
Ureteral involvement in xanthogranulomatous pyelonephritis- Rare manifestation


Department of Radio Diagnosis, IGMC, Shimla, India

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Keywords: Xanthogranulomatous pyelonephritis, ureter, CT

How to cite this article:
Sharma S, Jhobta A, Goyal D, Surya M, Sumala, Negi A. Ureteral involvement in xanthogranulomatous pyelonephritis- Rare manifestation. Indian J Radiol Imaging 2006;16:243-5

How to cite this URL:
Sharma S, Jhobta A, Goyal D, Surya M, Sumala, Negi A. Ureteral involvement in xanthogranulomatous pyelonephritis- Rare manifestation. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Nov 18];16:243-5. Available from: http://www.ijri.org/text.asp?2006/16/2/243/29101
Xanthogranulomatous pyelonephritis (XGPN) is an uncommon form of granulomatous inflammation characterized by destruction of the renal parenchyma and replacement by solid sheets of lipid- laden macrophages [1]. The process may be focal (10-17%) or diffuse (83-90%) with extension of inflammation out side the kidney. This entity is of particular interest to the radiologist, as the focal type may mimic renal cell carcinoma, while the diffuse form has imaging features which are characteristic [2]. XGPN is usually confined to the kidney, extension and involvement of ureter though reported, is rare [3]. We report one such case of XPGN having characteristic CT findings with involvement of the ureter.


   Case report Top


A 45 years old woman presented with the history of pain in the right loin. There was no history of dysurea or fever. The haemogram was unremarkable. Plain radiograph KUB revealed a large staghorn calculus in the right renal area [Figure - 1]. On USG, the right kidney was poorly visualized; instead multiple calculi surrounded by echogenic fat were seen. The urinary bladder showed a thin walled cyst of 1.2cm in size in relation to the right ureterovesical junction [Figure - 2]. CT scan confirmed the staghorn calculus in the right kidney. The right renal parenchyma and the perinephric space were infiltrated by a fat density (-30 to -55 HU) mass which showed no enhancement on post contrast scans. Also, there was no excretion of contrast by the right pelvicalcyceal system. The Gerota's fascia was thickened and the fat planes with the adjacent small bowel and the IVC were lost [Figure - 3],[Figure - 4]. The wall of right ureter was thickened with fat density within its lumen [Figure - 5]. The thickening extended till the right ureterovesical junction and terminated as a cystic mass projecting into the lumen of urinary bladder.


   Discussion Top


XPGN is predominantly seen in middle aged women. Clinically the patient presents with recurrent fever, dysuria & flank pain that is unresponsive to antibiotics [4]. The disease is usually unilateral. It is the sequalae of severe, chronic obstructing parenchymal inflammation. The inflammatory process begins in the pelvis & produces gradual destruction of medulla & cortex by direct extension. In the diffuse form, the kidney is enlarged, the renal pelvis is usually dilated and contains staghorn calculus in 75%patients [1]. The surrounding parenchyma is converted to shaggy golden yellow tissue. Extension of inflammation into the perinephric space is common with invasion into the pararenal spaces, psoas muscle, small bowel, diaphragm, lung or soft tissues [5]. Involvement of ureter though reported, is rare [3],[4].

In imaging, CT is the modality of choice, though plain radiograph and US are the initial examinations [2]. Plain scout radiograph shows a staghorn calculus. On intravenous urography, an absent nephrogram or focally absent nephrogram is seen [5]. US typically shows an enlarged kidney with multiple anechoic or hypoechoric areas with a central staghorn calculus. The renal parenchyma is thinned and corticomedullary differentiation is lost. Sound transmission may be poor due to perinephric fat as was seen in our case [4].

CT scan demonstrates a large reniform mass with a central staghorn calculus. The renal parenchyma is replaced by multiple low attenuation (-15 to +15 HU) areas representing dilated calyces and abscess cavities filled with pus and debris [6],[7]. Less common findings are a small contracted destroyed kidney with abundant perinephric fat (replacement lipomatosis) [1], as was the CT picture in our case.

XGPN has mainly to be differentiated from renal replacement lipomatosis. Both show a staghorn calculus with a non functioning kidney. But, on CT there is low attenuation material (+15 to -15 HU) filling the calyces in XGPN, whereas renal replacement lipomatosis shows attenuation of pure fat [7]. Other fat containing tumours such as angiomyolipom, lipoma or liposarcoma may be considered in differential diagnosis, but the absence of a staghorn calculus & a normally functioning kidney differentiates it from XGPN [7].

CT is also the modality of choice in depicting perinephric extension [1]. In our patient also, infiltration into small bowel & IVC was shown and confirmed on surgery. CT also depicted extension into ureter. Though CT features of ureteral involvement have not been reported but ureteral involvement has been confirmed on surgery [6],[7]. The dilated, thickened and fat containing ureter which was not well demonstrated on US, was clearly visualized on CT. CT further clarified that the cyst seen on US in relation to right ureterovesical junction was continuation of the involved ureter. CT features of ureter involvement have not been reported, by other authors but characteristic findings could be demonstrated in the present case which were confirmed on surgery and histopathology.

Some of these patients present with ureterocolic fistula. Also postoperative complications such as sinus and bowel fistula have been reported and these are usually due to failure to diagnose and properly stage the extent of disease [7]. Till date, CT shows the greatest promise in the preoperative identification and assessment of extent of XPGN especially involvement of ureters.

 
   References Top

1.Goldman SM, Hartman DS, Fistiman EK. CT of xanthogranulomatous pyelonephritis: Radiologic- Pathologic Correlation. AJR May 1984; 141:963-969.  Back to cited text no. 1    
2.Kenney PJ, Breatnach ES. Chronic Inflammation. In. Pollock HM. Clinical Urography an Atlas and Text book of Urological Imaging. WB Sunders,1990:807-835.  Back to cited text no. 2    
3.Mandal AK, Vaiphei KK, Bhusnurmath SR. Ureteral involvement in stage 1 xanthogranulomatous pyelonephritis - (a case report). JPGM, 1989; 35 (4): 215-216.  Back to cited text no. 3    
4.Davidson AJ, Hartman DS. Diagnostic set: Large multifocal, unilateral. In Radiology of the Kidney & Urinary tract 2nd ed. WB Sunders, 1994: 309-313.  Back to cited text no. 4    
5.Bianchi G, Franzolin N. Renojejunal fistula caused by xanthogranulomatous pyelonephritis. Br J urol 1980; 52-66.  Back to cited text no. 5    
6.Subramanyam BR, Boswale MA. Replacement lipomatosis of the Kidney: Diagnosis by Computed Tomography and Sonography. Radiology 1983; 148: 791-792.  Back to cited text no. 6    
7.Frederick GM, Hall BP. Case 4: Replacement lipomatosis of the kidney. AJR June 1995; 165: 200  Back to cited text no. 7    

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Correspondence Address:
S Sharma
1007, Vasant Vihar, Kasumpati, Shimla- 171009 (H.P)
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.29101

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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]

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