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Arteriography and Antibiotic Therapy of A Renal Carbuncle
Vol. 107, /,pril Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
ARTERIOGRAPHY AND ANTIBIOTIC THERAPY OF A RENAL CARBUNCLE ROBERT W. LYONS, JOHN M. LONG, BERNARD LYTTON AND VINCENT T. ANDRIOLE From the Departments of Internal Medicine, Radiology and Urology, Yale University School of Medicine, New Haven, Connecticut
A renal carbuncle is a localized abscess of the renal cortex commonly caused by the staphylococcus. Surgical drainage is the usual method of treatment of such lesions. Only 3 cases of renal carbuncle have been treated successfully with antibiotics alone. In 1957 Colby reported on the successful use of penicillin in one case. 1 In 1966 Cobb reported on 2 cases, one of which responded to tetracycline and the other to streptomycin. 2 Herein is described the fourth case of renal carbuncle successfully treated with antibiotics alone. Our patient was treated with penicillinase-resistant penicillins, the agents of choice for most staphylococcal infections today. Renal arteriography was used before treatment to delineate the lesion and after treatment to document the cure. To our knowledge this is the only case in which pre-treatment and post-treatment angiography have been done. CASE REPORT
D. C., an 18-year-old white man, presented at the infectious disease clinic on January 8, 1970 because of fever and chills 3 weeks in duration with steadily increasing left flank pain and 10 pound weight loss. Seven weeks previously he had had a staphylococcal infection in the right cheek that had been treated with hot soaks and a 3-day course of dicloxacillin. The lesion had healed without incident. Several microscopic analyses of the patient's urine had been normal. He was pale and looked chronically ill. Temperature was lOOF. The only abnormalities noted on examination were a tender, ill-defined mass in the left flank and marked left costovertebral angle tenderness. Hematocrit was 33 per cent. White blood count was 13,000 with a normal differential. The erythrocyte sedimentation rate was 56 mm. per hour (Wintrobe). Blood urea nitrogen was 13 mg. per 100 ml. The urine was normal on microscopic analysis and contained no protein or glucose. No organisms were seen on Gram stain of the urinary sediment. The patient was admitted to the hospital with a tentative diagnosis of renal carbuncle or perinephric abscess. Excretory urography (IVP) and nephrotomography demonstrated a normal kidney and colAccepted for publication May 14, 1971. Aided by a grant from the American Heart Association and by grants AI 06308 and AI 271 from the United States Public Health Service. 1 Colby, F. H., Baker, M. P. and St. Goar, W. T.: Renal carbuncle; report of a response to modern treatment. New Engl. J. Med., 266: 1147, 1957. 2 Cobb, 0. E.: Carbuncle of the kidney. Brit. J. Urol., 38: 262, 1966.
lecting system on the right side. A mass in the lower pole of the left kidney distorted the infundibulum and calices and medially displaced the proximal ureter (fig. 1, A). A renal arteriogram confirmed the enlargement of the lower pole. The arterial phase of the selective injection demonstrated attenuation of the smaller opacified arteries by the expanding mass (fig. 1, B). On the nephrogram phase the stain of the lower pole was irregular with loss of definition of the cortical margin. There were no encased or amputated vessels nor was there any neovascularity to suggest malignancy. The renal vein was patent. Further blood studies showed a marked increase in the serum haptoglobin (420 mg. per 100 ml.) and the serum a2 globulin (1.18 gm. per 100 ml.), and a decrease in the serum albumin (2.93 gm. per 100 ml.) and serum 'Y globulin (0.65 gm. per 100 ml.). Blood and urine cultures done at hospitalization yielded no organisms. The patient was treated initially with 2 gm. oxacillin every 4 hours, and he became afebrile after 24 hours. In 48 hours the pain disappeared. He continued to receive daily 12 gm. oxacillin intravenously for 2 weeks. He was discharged from the hospital on January 22 and continued on 1 gm. cloxacillin per day orally until February 26. During this time the hematocrit rose to 45 per cent and sedimentation rate fell to 8 mm. per hour. On April 5 the patient was readmitted to the hospital for a repeat arteriogram. He had been well since discharge from the hospital, and the renal arteriogram was normal (fig. 2). DISCUSSION
In 1905 Israel first described renal carbuncle. 3 He reported on a patient with a staphylococcal skin infection in whom a localized renal parenchymal lesion developed after a blow in the flank. Several large reviews during the 1930's established the symptoms and natural history of the disease.a- 5 Renal carbuncle usually arises a few weeks after a staphylococcal skin or respiratory infection. The original lesion may be healed when the patient is first seen. The patient comes to the physician because of chills, fever and back pains, and when examined he often has a palpable flank mass. 3 Graves, R. C. and Parkins, L. E.: Carbuncle of the kidney. J. Urol., 35: 1, 1936. 4 Spence, H. M. and Johnston, L. W.: Renal carbuncle; case report and comparative review. Ann. Surg., 109: 99, 1939. 6 Ingrish, G. A.: Carbuncle of the kidney: report of ten cases. J. Ural., 42: 326, 1939.
524
RENAL CARBUNCLE
525
Fm. 1. A, IVP demonstrates mass of lower pole of left kidney with local distortion of collecting and medial deviation of ureter. B, arterial phase of selective left renal arteriogram. Peripheral of lower pole are attenuated and separated in comparison to normal upper pole. No tumor vessels are present. Usually, no bacteria or blood cells are found in the urine and urine culture no organisms. The diagnosis is often made only after surgical exploration which is performed in some cases because of the difficulty in distinguishing the renal mass from a carcinoma. 6 In our patient renal carcinoma was a possibility. Fever, anemia and a high serum haptoglobin are a triad associated with hypernephroma. 7 The initial renal angiogram was of considerable value in planning therapy. The renal angiographic findings Caplan and associates agree with those described in acute inflammatory space-occupying lesions of the kidney. 8 Renal angiography is highly reliable in excluding neoplasia. However, errors are possible. :.\1eaney recently reported on a series of 497 unselected patients with renal masses in which 10 malignant tumors were incorrectly diagnosed. 9 Difficulties arise in renal cell carcinomas which may become highly necrotic and in relatively avascular tumors such as papillary adenocarcinomas and metastatic lesions. However, in our case, the lack of any sign of malignancy supported the decision to treat the patient with antibiotics. The correctness of this decision was confirmed the patient's prompt clinical response. The followup arteriogram obtained Doolittle, K. H. and Taylor, J. N.: Renal abscess in the differential diagnosis of mass in kidney. J. Urol., 89: 649, 1963. 7 Bowman, H. S. and Martinez, E. J.: Fever, anemia, and hyperhaptoglobinemia: an extrarenal triad of hypernephroma. Ann. Intern. 68: 613, 1968. 8 Caplan, L. H., Siegelman, S. Bosniak, M. A.: Angiography in inflammatory space-occupying lesions of the kidney. Radiology, 88: 14, 1967. 9 Meaney, T. F.: Errors in angiographic diagnosis of renal masses. Radiology, 93: 361, 1969. 6
Fm. 2. Arterial phase of post-treatment arteriogram. Expansion of lower pole is no longer present. Vessels appear normal. 5 weeks after the antibiotic course had been completed was entirely normal, thus indicating resoJu. tion of the infection and excluding underlying nancy. Penicillinase-resistant penicillins should be used as the initial treatment of renal
526
LYONS AND ASSOCIATES
if the diagnosis can be made more certain by renal arteriography. We would emphasize that the dose should be high and the duration of treatment long. Thick walled abscesses may require surgical drainage but an initial course of antibiotics would be warranted to improve the patient's condition before operation.
SUMMARY
An 18-year-old man was cured of a renal carbuncle by treatment with penicillinase-resistant penicillins. Renal arteriography was used before and after therapy to delineate the lesion and to document its healing.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
ARTERIOGRAPHY AND ANTIBIOTIC THERAPY OF A RENAL CARBUNCLE ROBERT W. LYONS, JOHN M. LONG, BERNARD LYTTON AND VINCENT T. ANDRIOLE From the Departments of Internal Medicine, Radiology and Urology, Yale University School of Medicine, New Haven, Connecticut
A renal carbuncle is a localized abscess of the renal cortex commonly caused by the staphylococcus. Surgical drainage is the usual method of treatment of such lesions. Only 3 cases of renal carbuncle have been treated successfully with antibiotics alone. In 1957 Colby reported on the successful use of penicillin in one case. 1 In 1966 Cobb reported on 2 cases, one of which responded to tetracycline and the other to streptomycin. 2 Herein is described the fourth case of renal carbuncle successfully treated with antibiotics alone. Our patient was treated with penicillinase-resistant penicillins, the agents of choice for most staphylococcal infections today. Renal arteriography was used before treatment to delineate the lesion and after treatment to document the cure. To our knowledge this is the only case in which pre-treatment and post-treatment angiography have been done. CASE REPORT
D. C., an 18-year-old white man, presented at the infectious disease clinic on January 8, 1970 because of fever and chills 3 weeks in duration with steadily increasing left flank pain and 10 pound weight loss. Seven weeks previously he had had a staphylococcal infection in the right cheek that had been treated with hot soaks and a 3-day course of dicloxacillin. The lesion had healed without incident. Several microscopic analyses of the patient's urine had been normal. He was pale and looked chronically ill. Temperature was lOOF. The only abnormalities noted on examination were a tender, ill-defined mass in the left flank and marked left costovertebral angle tenderness. Hematocrit was 33 per cent. White blood count was 13,000 with a normal differential. The erythrocyte sedimentation rate was 56 mm. per hour (Wintrobe). Blood urea nitrogen was 13 mg. per 100 ml. The urine was normal on microscopic analysis and contained no protein or glucose. No organisms were seen on Gram stain of the urinary sediment. The patient was admitted to the hospital with a tentative diagnosis of renal carbuncle or perinephric abscess. Excretory urography (IVP) and nephrotomography demonstrated a normal kidney and colAccepted for publication May 14, 1971. Aided by a grant from the American Heart Association and by grants AI 06308 and AI 271 from the United States Public Health Service. 1 Colby, F. H., Baker, M. P. and St. Goar, W. T.: Renal carbuncle; report of a response to modern treatment. New Engl. J. Med., 266: 1147, 1957. 2 Cobb, 0. E.: Carbuncle of the kidney. Brit. J. Urol., 38: 262, 1966.
lecting system on the right side. A mass in the lower pole of the left kidney distorted the infundibulum and calices and medially displaced the proximal ureter (fig. 1, A). A renal arteriogram confirmed the enlargement of the lower pole. The arterial phase of the selective injection demonstrated attenuation of the smaller opacified arteries by the expanding mass (fig. 1, B). On the nephrogram phase the stain of the lower pole was irregular with loss of definition of the cortical margin. There were no encased or amputated vessels nor was there any neovascularity to suggest malignancy. The renal vein was patent. Further blood studies showed a marked increase in the serum haptoglobin (420 mg. per 100 ml.) and the serum a2 globulin (1.18 gm. per 100 ml.), and a decrease in the serum albumin (2.93 gm. per 100 ml.) and serum 'Y globulin (0.65 gm. per 100 ml.). Blood and urine cultures done at hospitalization yielded no organisms. The patient was treated initially with 2 gm. oxacillin every 4 hours, and he became afebrile after 24 hours. In 48 hours the pain disappeared. He continued to receive daily 12 gm. oxacillin intravenously for 2 weeks. He was discharged from the hospital on January 22 and continued on 1 gm. cloxacillin per day orally until February 26. During this time the hematocrit rose to 45 per cent and sedimentation rate fell to 8 mm. per hour. On April 5 the patient was readmitted to the hospital for a repeat arteriogram. He had been well since discharge from the hospital, and the renal arteriogram was normal (fig. 2). DISCUSSION
In 1905 Israel first described renal carbuncle. 3 He reported on a patient with a staphylococcal skin infection in whom a localized renal parenchymal lesion developed after a blow in the flank. Several large reviews during the 1930's established the symptoms and natural history of the disease.a- 5 Renal carbuncle usually arises a few weeks after a staphylococcal skin or respiratory infection. The original lesion may be healed when the patient is first seen. The patient comes to the physician because of chills, fever and back pains, and when examined he often has a palpable flank mass. 3 Graves, R. C. and Parkins, L. E.: Carbuncle of the kidney. J. Urol., 35: 1, 1936. 4 Spence, H. M. and Johnston, L. W.: Renal carbuncle; case report and comparative review. Ann. Surg., 109: 99, 1939. 6 Ingrish, G. A.: Carbuncle of the kidney: report of ten cases. J. Ural., 42: 326, 1939.
524
RENAL CARBUNCLE
525
Fm. 1. A, IVP demonstrates mass of lower pole of left kidney with local distortion of collecting and medial deviation of ureter. B, arterial phase of selective left renal arteriogram. Peripheral of lower pole are attenuated and separated in comparison to normal upper pole. No tumor vessels are present. Usually, no bacteria or blood cells are found in the urine and urine culture no organisms. The diagnosis is often made only after surgical exploration which is performed in some cases because of the difficulty in distinguishing the renal mass from a carcinoma. 6 In our patient renal carcinoma was a possibility. Fever, anemia and a high serum haptoglobin are a triad associated with hypernephroma. 7 The initial renal angiogram was of considerable value in planning therapy. The renal angiographic findings Caplan and associates agree with those described in acute inflammatory space-occupying lesions of the kidney. 8 Renal angiography is highly reliable in excluding neoplasia. However, errors are possible. :.\1eaney recently reported on a series of 497 unselected patients with renal masses in which 10 malignant tumors were incorrectly diagnosed. 9 Difficulties arise in renal cell carcinomas which may become highly necrotic and in relatively avascular tumors such as papillary adenocarcinomas and metastatic lesions. However, in our case, the lack of any sign of malignancy supported the decision to treat the patient with antibiotics. The correctness of this decision was confirmed the patient's prompt clinical response. The followup arteriogram obtained Doolittle, K. H. and Taylor, J. N.: Renal abscess in the differential diagnosis of mass in kidney. J. Urol., 89: 649, 1963. 7 Bowman, H. S. and Martinez, E. J.: Fever, anemia, and hyperhaptoglobinemia: an extrarenal triad of hypernephroma. Ann. Intern. 68: 613, 1968. 8 Caplan, L. H., Siegelman, S. Bosniak, M. A.: Angiography in inflammatory space-occupying lesions of the kidney. Radiology, 88: 14, 1967. 9 Meaney, T. F.: Errors in angiographic diagnosis of renal masses. Radiology, 93: 361, 1969. 6
Fm. 2. Arterial phase of post-treatment arteriogram. Expansion of lower pole is no longer present. Vessels appear normal. 5 weeks after the antibiotic course had been completed was entirely normal, thus indicating resoJu. tion of the infection and excluding underlying nancy. Penicillinase-resistant penicillins should be used as the initial treatment of renal
526
LYONS AND ASSOCIATES
if the diagnosis can be made more certain by renal arteriography. We would emphasize that the dose should be high and the duration of treatment long. Thick walled abscesses may require surgical drainage but an initial course of antibiotics would be warranted to improve the patient's condition before operation.
SUMMARY
An 18-year-old man was cured of a renal carbuncle by treatment with penicillinase-resistant penicillins. Renal arteriography was used before and after therapy to delineate the lesion and to document its healing.