A Lethal Case of a 3B Stage Emphysematous Pyelonephritis

Emphysematous pyelonephritis (EPN) is a rare, necrotising infection of the renal parenchyma, leading to the accumulation of gas within the kidney and in the perinephric space. Patients with diabetes account for 85-100% of cases. The current treatment is one of the potent antimicrobial therapies together with kidney drainage and fluid resuscitation. Nephrectomy should be considered if patients deteriorate or do not improve on conservative treatment. We report a case of 62-year-old woman with multiple comorbidities, with a diagnosis of EPN whose condition did not improve despite the standard treatment approach.

Laparoscopic Resection of Renal Capsular Endometriosis in a Woman with Menstrual-Related Flank Pain: Case Report

Background Although involvement of the urinary system is not uncommon, endometriosis in the kidneys is rare. To date, laparoscopic partial nephrectomy has been the preferred approach for managing renal endometriosis. Here, we report for the first time the results of laparoscopic removal of a renal capsular endometriosis in a malrotated kidney in an attempt to save the whole kidney parenchyma, in terms of feasibility and safety. Case presentation A 37-year-old female presented with periodic right flank pain associated with her menstrual cycle. On imaging, a malrotated right kidney and a hypodense irregular-shaped lesion measuring 30 * 20 * 15 mm were seen in the superior portion of the right perinephric space. Histologic evaluation of the ultrasound-guided biopsy was consistent with renal capsular endometriosis. The patient underwent laparoscopic surgery to remove the capsular mass while preserving the normal renal parenchyma. Pathological examination of the biopsy obtained during surgery was in favor of renal endometriosis. At 6-month follow-up, the patient’s pain had completely disappeared and no complications had occurred. In addition, imaging did not show any remarkable recurrence. Conclusion Renal endometriosis should be strongly considered as a differential diagnosis in female patients with a renal capsular mass and exacerbation of flank pain during menstruation. Based on our experience, with preoperative needle biopsy and clearing the pathology, laparoscopic removal of the mass in spite of renal anatomic abnormality is feasible and safe and thus could be considered as a possible treatment option.

Surgical management of spontaneously ruptured kidney with peritonitis due to neglected renal and ureteric calculi

A 30-year-old woman presented with right-sided abdominal pain associated with fever. Her ultrasound showed right renal calculus with no hydronephrosis along with collection in peritoneal cavity and pouch of Douglas. CT showed ruptured right kidney with multiple renal and ureteric calculi as well as displaced renal calculi in perinephric space and pararenal space. Exploratory laparotomy and right nephroureterectomy were done. Nephrolithiasis with secondary infection makes the kidney fragile due to pathological changes, which may cause rupture of the renal calyces with trivial trauma or may be spontaneous. Distal obstruction by the stone and increased back pressure in the calyces may have added to the spontaneous rupture of the calyx and subsequently renal parenchyma. Management includes early exploration with nephrectomy and it is often life saving.

Complete Radiological Response of Recurrent Metastatic Adrenocortical Carcinoma to Pembrolizumab and Mitotane

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Treatment options for ACC are limited, with resection the main intervention. Most cases present in late metastatic cases, and data regarding effective therapies is limited. We report a case of ACC in a 40-year-old woman with history of ACC postadrenalectomy, who presented with recurrent metastatic ACC in the left perinephric space. She was started on pembrolizumab which was added to her mitotane maintenance therapy. Complete radiological response was achieved after 4 cycles of pembrolizumab. As far as we know, this is the first case to achieve complete radiological response with mitotane and pembrolizumab in recurrent metastatic ACC, with negative prognostic markers and no prior radiotherapy. As our findings are in the setting of one clinical case, we suggest the need to perform a trial to assess the benefit of combining mitotane and pembrolizumab in treating metastatic ACC.

Feline abdominal ultrasonography: What’s normal? What’s abnormal? Renal pelvis, ureters and urinary bladder

Practical relevance: Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. Ultrasound examination of the urinary tract provides important information useful in the investigation of several conditions including ureteral obstruction and cystitis. Clinical challenges: Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even for the experienced ultrasonographer, differentiating between incidental findings, such as lipid droplets in the bladder, and pathological changes can be challenging. Aim: This review, part of an occasional series on feline abdominal ultrasonography, discusses the ultrasonographic examination of the normal and diseased renal pelvis, ureters and urinary bladder. Aimed at general practitioners who wish to improve their knowledge of and confidence in feline abdominal ultrasound, this review is accompanied by high-resolution images and videos available online as supplementary material. Ultrasound examination of the kidneys and perinephric space was discussed in an article published in May 2020. Equipment: Ultrasound facilities are readily available to most practitioners, although the use of ultrasonography as a diagnostic tool is highly dependent on operator experience. Evidence base: Information provided in this article is drawn from the published literature and the author’s own clinical experience.

Feline abdominal ultrasonography: what’s normal? what’s abnormal? The kidneys and perinephric space

Practical relevance: Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. Ultrasound examination of the kidneys and perinephric space can provide important information on several conditions including chronic renal disease, hydronephrosis and perinephric pseudocyst formation. Clinical challenges: Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even for the experienced ultrasonographer, differentiating between incidental findings, such as a medullary rim sign, and pathological changes can be challenging. Aim: This review, part of an occasional series on feline abdominal ultrasonography, discusses ultrasonographic examination of the normal and diseased kidney and perinephric space. Aimed at general practitioners who wish to improve their knowledge of and confidence in feline abdominal ultrasound, this review is accompanied by high-resolution images and videos available online as supplementary material. A subsequent article will address ultrasonography of the collecting system including the renal pelvis and urinary bladder. Equipment: Ultrasound facilities are readily available to most practitioners, although use of ultrasonography as a diagnostic tool is highly dependent on operator experience. Evidence base: Information provided in this article is drawn from the published literature and the author’s own clinical experience.

XANTHOGRANULOMATOUS PYELONEPHRITIS

Xanthogranulomatous pyelonephritis (XPN) is an uncommon form of chronic pyelonephritis and extremely rare in pediatrics. A six-year-old female presented with a six-month history of recurrent urinary tract infections treated with multiple antibiotics without clinical improvement. Computerized tomography (CT) of the patient’s abdomen/pelvis showed a right renal mass that extended posteriorly into the perinephric space and the right psoas muscle. A CT-guided percutaneous biopsy was performed that ruled out malignancy and showed XPN. Although very rare, XPN should be considered in patients with recurrent or persistent infections of the kidney.

Perinephric urinoma following spontaneous renal rupture in the third trimester of pregnancy: a case report and brief review of the literature

Background Spontaneous formation of urinoma is a rare condition, especially for pregnant women. We report a patient in the third trimester of pregnancy with a spontaneous renal rupture who then develops a urinoma from urine leaking into the perinephric space. Case presentation A 23-year-old primagravida was diagnosed with a spontaneous renal rupture and acute left loin pain accompanied by hematuria when she was 35 weeks pregnant. A sub-capsular perinephric cyst then developed to a size of 319 × 175 × 253 mm, and because of discomfort to the patient, we performed Cesarean section. After a healthy male newborn was delivered, fluid was suctioned from a large perirenal cyst that had an estimated size of 300 × 200 × 300 mm. A percutaneous nephrostomy tube was left in the cyst until CT showed no remaining fluid. In the six-month follow-up, the patient showed no perirenal extravasation according to an ultrasound scan, and the urine analysis and renal function tests were normal. Conclusion Close follow-up should be recommended for the patient who has renal rupture after conservative therapy, especially for pregnant woman. CT or MRI should be considered in addition to utilizing ultrasound in the management of pregnant women who present with urinomas. Percutaneous nephrostomy is suggested as an appropriate treatment for large urinomas.