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Unilateral Pyelonephritis, Accompanied By Hypertension, Relieved By Nephrectomy
THE JOURNAL OF UROLOGY
Vol. 67, No. 2, February 1952 P.intcd in U.S.A.
-CNILATERAL PYELONEPHIUTIS, ACCOMPANIED BY HYPERTENSION, RELIEVED BY NEPHRECT0 1•.VIY BYROK J. HOFFMAN, M. K BAILEY
AND
CHESTER A. FORT
From the Medical and Urological Services of Emory University Hospital, Atlanta, Ga.
Goldblattt, 2 created much interest in the relationship between generalized hypertensive vascular disease and unilateral renal disorders by demonstrating an elevation in blood pressure following constriction of one renal artery with a silver clamp. He later observed that hypertension following renal ischemia immediately returned to normal after removal of the affected kidney. Gasul et al. 3 recently reviewed the literature and found only 31 cases of hypertension corrected by nephrectomy. Nine of the cases were children and in 8 of these, the hypertension was associated with unilateral pyelonephritis. The case reported here is one of advanced unilateral pyelonephritis accompanied by hypertension which was corrected by nephrectomy. CASE REPORT
Mrs. K. K., a white woman, aged 27, was first seen on May 21, 1948, complaining of high blood pressure, nervousness with tightness in her chest, loss of appetite and episodes of nausea and vomiting when food was forced. She had known of her hypertension since her first pregnancy 9 years previously and had been informed then that the elevation in blood pressure was due to toxemia of of pregnancy. She lost the child following premature delivery at 7½ months. Her second pregnancy was interrupted at 8 months by cesarian operation because of elevation of blood pressure, nausea, vomiting and general toxemia. At operation a portion of both fallopian tubes was removed for the purpose of sterilization. She was 19 years of age at this time. During the following years the patient visited many doctors and clinics because of her hypertension which caused her great anxiety because her father had suffered with angina pectoris and had died suddenly with a heart attack at 43 years of age and she feared that her high blood pressure was leading her to the same end. She was advised by some physicians to have a sympathectomy for relief of her hypertension and was also told that one kidney did not function as ,Yell as the other but that there were no remedial measures to be undertaken. The past history was irrelevant except for a severe and persistent sore throat for several weeks at the age of two or three. This was followed by an unexplained elevation of temperature and general debility for a number of months. The patient stated that her mother had always regarded her as being in poor health during childhood. The patient displayed great anxiety about herself. She weighed 117 pounds and was 5 feet 3 inches in height. The skin was a little dry but her hair and nails were of good texture. The pupils were normal and reacted equally to light and 1
Goldblatt, H., Lynch, G., Hauze!, R. F. and Summerville, W.W.: Am. J. Path., 9:
042, 1033. 2
3
Goldblatt, H. et al.: J. Exp. Med., 59: 347, 1934. Gasul, B. M., Glaser, J. M. and Grossman, A.: J.A.IVI.A., 139: 305, 1949. 132
UNILATERAL PYELONEPHRITIS AND NEPHRECTOMY
133
accommodation. The conjunctivae were slightly hyperemic and both fundi showed grade 1 to 2 irregular spasm of the arteries and terminal arterioles without exudates or hemorrhages. The lungs were clear. Blood pressure varied from 160/108 to 144/100 and was without appreciable alteration when the patient changed from the prone to the sitting position. The heart was normal in size. There were no murmurs, the tones were of good quality, the rhythm was regular and the rate 80. The liver and spleen were normal in size. Pelvic examination revealed slight tenderness in both fornices on bimanual palpation but there were no masses. The uterus was anteflexed and normal in size. Urinalysis: On repeated specimens the specific gravity varied from 1.005 to 1.015 and a faint trace of albumin was present in almost all of them. There was no sugar. Microscopic examination revealed 7 to 12 pus cells, a rare red blood cell, and many gram negative bacilli and gram positive cocci. Blood count: The erythrocyte count was 5,330,000 and the hemoglobin 16.5 gm. (97 per cent). The leukocytes numbered 11,000 with 59 per cent segmented forms, 37 per cent lymphocytes, 3 per cent monocytes, and 1 per cent basophils
FIGURE
1
The blood sedimentation rate (Westergren) was 2 mm. in 1 hour. The blood cholesterol was 271 mg. per cent and the nonprotein nitrogen 28 mg. per cent. Excretory urography revealed no excretion of contrast medium on the right, with a small oval shaped shadow measuring 7 by 4 mm. located in the lower part of the right renal shadow. The left kidney was large, its shadow well outlined, and the contrast medium demonstrated a normal pelvis and calyces. The patient was hospitalized for further study. Blood pressure determinations continued at the same levels formerly observed. The cold pressor test was negative. Repeated blood nonprotein nitrogen was 25 mg. per cent and creatinine 1.8 mg. per cent. Cystoscopic examination revealed a normal bladder and retrograde pyelogram demonstrated the same finding as had the excretory urogram: a normal left urinary tract and a small right kidney with a dilated pelvis (fig. 1). It was decided that this was a Goldblatt kidney and right nephrectomy was done without incident. Grossly, the kidney was very much smaller than it had appeared on the pyelogram but it was freed with very little difficulty. The right kidney weighed 23 gm. after removal, had attached a segment of
134
B. J. HOFFMAN, M. K. BAILEY AND C. A. FORT
FIGURE
2
ureter measuring 6 cm. and contained a small stone in the lower calyx measuring approximately 5 by 3 mm. The capsule stripped with difficulty leaving a pale reddish to light tan cortical surface through which were scattered large light colored fibrous areas. On cut section the cortex measured less than 1 mm.
UNILATERAL PYELONEPHRITIS AND NEPHRECTOMY
135
in thickness and the pyramidal areas were small and indistinct, along with a moderate increase of peripelvic fat. Microscopic examination revealed large and extensive areas of interstitial fibrosis with marked lymphocytic infiltration, advanced vascular changes, and a few patchy areas of tubular dilatation (fig. 2, A). The dilated tubules were lined by flattened epithelium and contained amorphous protein material and hyaline casts. In a few scattered areas the renal parenchyma was better preserved and the glomeruli appeared normal except for some thickening of Bowman's capsule. Vascular changes were prominent. The medium and small arteries demonstrated marked fibrous proliferation with thick concentric bands of fibrous tissue surrounding a small lumen, giving a picture of endarteritis rather than the usual subintimal hyaline thickening (fig. 2, B). Sections through the pelvic mucosa revealed marked and extensive lymphocytic infiltration throughout the subepithelial tissue with a few scattered small lymph follicles (fig. 2, C). After reacting from anesthesia, the patient's blood pressure was 118/76 and during the 10-day period of hospitalization it varied from 120/68 to 136/98. The urine contained only an occasional epithelial and pus cell and was without bacteria. She became less emotional regarding her physical state and her anxiety was largely replaced by confidence. During the subsequent 2-year period of observation, her blood pressure has varied between 110/74 and 136/88 and the vessels of her retinae now show only the slightest irregularity instead of the preoperative grade 1 to 2 spasm. During December 1949, the patient suffered an unexplained fever which cleared spontaneously. A check-up cystoscopy and urinary tract study were normal and the urine is consistently free of albumin. DISCUSSION
This case is reported not to advocate nephrectomy as therapy for hypertension, but to emphasize that the simultaneous occurrence of hypertensive vascular disease and advanced unilateral renal disease is deserving of diagnostic consideration of renal hypertension, as distinguished from neurogenic, endocrine, or other forms. The presence in a child or young adult of one poorly functioning kidney with positive urinary findings and a history of severe and prolonged tonsilitis as a young child, followed by poor general health, would suggest advanced unilateral pyelonephritis. It is possible that the unilateral pyelonephritis in this case developed during her first pregnancy at the age of 18 but it is more probable that the toxemia of pregnancy on both occasions was superimposed on a pre-existing pyelonephritis. The eight years between her sterilization and nephrectomy render a conclusive evaluation impossible. However, a kidney weighing only 23 gm. in an advanced state of inflammatory fibrosis and contraction is compatible with disease from early childhood. If the latter situation existed 8 years ago and had been corrected, it is possible that the patient might have undergone her pregnancies without event. Her general clinical status began to improve immediately after nephrectomy.
136
D. J. HOFFMAN, M. K. DAILEY AND C. A. FORT
There was a rapid ·weight gain of 19 pounds in 7 months. Her general nervous status changed from one of anxiety to confidence. It might be considered that her psychic overlay had been corrected by doing something to her in the magnitude of a major operation, but the fact remains that a badly diseased and practically nonfunctioning kidney \Yas removed. SUMMARY
A case of hypertension with unilateral pyelonephritis relieved by nephrectom)' is reported. It is quite possible the unilateral kidney disease dates from severe and prolonged tonsillitis at 2 years of age. 1106 Nfcdical Arts Bldg., Atlanta, Ga.
Vol. 67, No. 2, February 1952 P.intcd in U.S.A.
-CNILATERAL PYELONEPHIUTIS, ACCOMPANIED BY HYPERTENSION, RELIEVED BY NEPHRECT0 1•.VIY BYROK J. HOFFMAN, M. K BAILEY
AND
CHESTER A. FORT
From the Medical and Urological Services of Emory University Hospital, Atlanta, Ga.
Goldblattt, 2 created much interest in the relationship between generalized hypertensive vascular disease and unilateral renal disorders by demonstrating an elevation in blood pressure following constriction of one renal artery with a silver clamp. He later observed that hypertension following renal ischemia immediately returned to normal after removal of the affected kidney. Gasul et al. 3 recently reviewed the literature and found only 31 cases of hypertension corrected by nephrectomy. Nine of the cases were children and in 8 of these, the hypertension was associated with unilateral pyelonephritis. The case reported here is one of advanced unilateral pyelonephritis accompanied by hypertension which was corrected by nephrectomy. CASE REPORT
Mrs. K. K., a white woman, aged 27, was first seen on May 21, 1948, complaining of high blood pressure, nervousness with tightness in her chest, loss of appetite and episodes of nausea and vomiting when food was forced. She had known of her hypertension since her first pregnancy 9 years previously and had been informed then that the elevation in blood pressure was due to toxemia of of pregnancy. She lost the child following premature delivery at 7½ months. Her second pregnancy was interrupted at 8 months by cesarian operation because of elevation of blood pressure, nausea, vomiting and general toxemia. At operation a portion of both fallopian tubes was removed for the purpose of sterilization. She was 19 years of age at this time. During the following years the patient visited many doctors and clinics because of her hypertension which caused her great anxiety because her father had suffered with angina pectoris and had died suddenly with a heart attack at 43 years of age and she feared that her high blood pressure was leading her to the same end. She was advised by some physicians to have a sympathectomy for relief of her hypertension and was also told that one kidney did not function as ,Yell as the other but that there were no remedial measures to be undertaken. The past history was irrelevant except for a severe and persistent sore throat for several weeks at the age of two or three. This was followed by an unexplained elevation of temperature and general debility for a number of months. The patient stated that her mother had always regarded her as being in poor health during childhood. The patient displayed great anxiety about herself. She weighed 117 pounds and was 5 feet 3 inches in height. The skin was a little dry but her hair and nails were of good texture. The pupils were normal and reacted equally to light and 1
Goldblatt, H., Lynch, G., Hauze!, R. F. and Summerville, W.W.: Am. J. Path., 9:
042, 1033. 2
3
Goldblatt, H. et al.: J. Exp. Med., 59: 347, 1934. Gasul, B. M., Glaser, J. M. and Grossman, A.: J.A.IVI.A., 139: 305, 1949. 132
UNILATERAL PYELONEPHRITIS AND NEPHRECTOMY
133
accommodation. The conjunctivae were slightly hyperemic and both fundi showed grade 1 to 2 irregular spasm of the arteries and terminal arterioles without exudates or hemorrhages. The lungs were clear. Blood pressure varied from 160/108 to 144/100 and was without appreciable alteration when the patient changed from the prone to the sitting position. The heart was normal in size. There were no murmurs, the tones were of good quality, the rhythm was regular and the rate 80. The liver and spleen were normal in size. Pelvic examination revealed slight tenderness in both fornices on bimanual palpation but there were no masses. The uterus was anteflexed and normal in size. Urinalysis: On repeated specimens the specific gravity varied from 1.005 to 1.015 and a faint trace of albumin was present in almost all of them. There was no sugar. Microscopic examination revealed 7 to 12 pus cells, a rare red blood cell, and many gram negative bacilli and gram positive cocci. Blood count: The erythrocyte count was 5,330,000 and the hemoglobin 16.5 gm. (97 per cent). The leukocytes numbered 11,000 with 59 per cent segmented forms, 37 per cent lymphocytes, 3 per cent monocytes, and 1 per cent basophils
FIGURE
1
The blood sedimentation rate (Westergren) was 2 mm. in 1 hour. The blood cholesterol was 271 mg. per cent and the nonprotein nitrogen 28 mg. per cent. Excretory urography revealed no excretion of contrast medium on the right, with a small oval shaped shadow measuring 7 by 4 mm. located in the lower part of the right renal shadow. The left kidney was large, its shadow well outlined, and the contrast medium demonstrated a normal pelvis and calyces. The patient was hospitalized for further study. Blood pressure determinations continued at the same levels formerly observed. The cold pressor test was negative. Repeated blood nonprotein nitrogen was 25 mg. per cent and creatinine 1.8 mg. per cent. Cystoscopic examination revealed a normal bladder and retrograde pyelogram demonstrated the same finding as had the excretory urogram: a normal left urinary tract and a small right kidney with a dilated pelvis (fig. 1). It was decided that this was a Goldblatt kidney and right nephrectomy was done without incident. Grossly, the kidney was very much smaller than it had appeared on the pyelogram but it was freed with very little difficulty. The right kidney weighed 23 gm. after removal, had attached a segment of
134
B. J. HOFFMAN, M. K. BAILEY AND C. A. FORT
FIGURE
2
ureter measuring 6 cm. and contained a small stone in the lower calyx measuring approximately 5 by 3 mm. The capsule stripped with difficulty leaving a pale reddish to light tan cortical surface through which were scattered large light colored fibrous areas. On cut section the cortex measured less than 1 mm.
UNILATERAL PYELONEPHRITIS AND NEPHRECTOMY
135
in thickness and the pyramidal areas were small and indistinct, along with a moderate increase of peripelvic fat. Microscopic examination revealed large and extensive areas of interstitial fibrosis with marked lymphocytic infiltration, advanced vascular changes, and a few patchy areas of tubular dilatation (fig. 2, A). The dilated tubules were lined by flattened epithelium and contained amorphous protein material and hyaline casts. In a few scattered areas the renal parenchyma was better preserved and the glomeruli appeared normal except for some thickening of Bowman's capsule. Vascular changes were prominent. The medium and small arteries demonstrated marked fibrous proliferation with thick concentric bands of fibrous tissue surrounding a small lumen, giving a picture of endarteritis rather than the usual subintimal hyaline thickening (fig. 2, B). Sections through the pelvic mucosa revealed marked and extensive lymphocytic infiltration throughout the subepithelial tissue with a few scattered small lymph follicles (fig. 2, C). After reacting from anesthesia, the patient's blood pressure was 118/76 and during the 10-day period of hospitalization it varied from 120/68 to 136/98. The urine contained only an occasional epithelial and pus cell and was without bacteria. She became less emotional regarding her physical state and her anxiety was largely replaced by confidence. During the subsequent 2-year period of observation, her blood pressure has varied between 110/74 and 136/88 and the vessels of her retinae now show only the slightest irregularity instead of the preoperative grade 1 to 2 spasm. During December 1949, the patient suffered an unexplained fever which cleared spontaneously. A check-up cystoscopy and urinary tract study were normal and the urine is consistently free of albumin. DISCUSSION
This case is reported not to advocate nephrectomy as therapy for hypertension, but to emphasize that the simultaneous occurrence of hypertensive vascular disease and advanced unilateral renal disease is deserving of diagnostic consideration of renal hypertension, as distinguished from neurogenic, endocrine, or other forms. The presence in a child or young adult of one poorly functioning kidney with positive urinary findings and a history of severe and prolonged tonsilitis as a young child, followed by poor general health, would suggest advanced unilateral pyelonephritis. It is possible that the unilateral pyelonephritis in this case developed during her first pregnancy at the age of 18 but it is more probable that the toxemia of pregnancy on both occasions was superimposed on a pre-existing pyelonephritis. The eight years between her sterilization and nephrectomy render a conclusive evaluation impossible. However, a kidney weighing only 23 gm. in an advanced state of inflammatory fibrosis and contraction is compatible with disease from early childhood. If the latter situation existed 8 years ago and had been corrected, it is possible that the patient might have undergone her pregnancies without event. Her general clinical status began to improve immediately after nephrectomy.
136
D. J. HOFFMAN, M. K. DAILEY AND C. A. FORT
There was a rapid ·weight gain of 19 pounds in 7 months. Her general nervous status changed from one of anxiety to confidence. It might be considered that her psychic overlay had been corrected by doing something to her in the magnitude of a major operation, but the fact remains that a badly diseased and practically nonfunctioning kidney \Yas removed. SUMMARY
A case of hypertension with unilateral pyelonephritis relieved by nephrectom)' is reported. It is quite possible the unilateral kidney disease dates from severe and prolonged tonsillitis at 2 years of age. 1106 Nfcdical Arts Bldg., Atlanta, Ga.