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Carbuncle of the Kidney: Report of Ten Cases1
CARBUNCLE OF THE KIDNEY: REPORT OF TEN CASES 1 GEORGE A. INGRISH
Carbuncle of the kidney may be defined in the light of our present knowledge as one stage of a progressive pathological process in which a localized metastatic staphylococcic nephritis has progressed to a walledoff coalescence of multiple cortical abscesses. According to most writers, Israel described the first case of carbuncle of the kidney in 1891. Since then approximately 120 papers on this subject have appeared in the literature, reporting a total of 136 cases. The increase in the number of reported cases in the past 10 years speaks more for a greater accuracy in diagnosis than an increase in the incidence of this true clinical entity. A brief summary of the 136 cases appearing in the literature followed by a more detailed description of an additional 10 unreported cases from the private urological practice of Dr. Frank M. Phifer is herewith presented. Sex: Male cases reported-84; female cases reported-32; sex not recorded-20. Primary foci in order of frequency: Cutaneous carbuncle; furunculosis; cellulitis; paronychia; and osteomyelitis. Causative Organism: Staphylococcus aureus-98; Staphylococcus albus-6; mixed infection-10; not recorded-22. Number and location of Carbuncle: Unilateral-110; bilateral-4; single lesions-104; multiple lesions-32; right side-86; left side-SO; associated with a perinephritic abscess-14. Treatment: There appears to be considerable variation of opinion as to the proper surgical procedure, varying from decapsulation of the kidney with incision, curettment and drainage (Beer), excision, to partial or complete nephrectomy. There is also a group of men who have advocated medical management, consisting of antiphlogistic measures, use of vaccines and deep x-ray therapy. They base their contention for this line of treatment on the fact that many postmortem findings show evidence of apparently healed cortical lesions. A complete discussion of the literature would be superfluous, as several authors (Graves and Parkins, and others) recently reported this subject in detail. It is felt that a brief report of the following cases would be of some value, as an accurate preoperative diagnosis was made in all but 2 cases. 1
Read before Chicago Urological Association February 1938. 326
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In making a diagnosis of carbuncle the following characteristic :findings were present in all cases: (1) gradual onset of fever, chills, malaise, associated with lumbar or abdominal pain; (2) physical :findings: a varying degree of tenderness with a stony hard, flat, costovertebral rigidity, this in all probability being due to the thickened, leathery, fatty capsule. Costovertebral fullness was only present in those cases with an associated perinephric abscess; (3) history of some form of cutaneous suppuration, occurring from 2 weeks to 2 months preceding renal symptoms; (4) urine was essentially negative in most cases; (5) x-ray examination usually revealed an obliteration of psoas shadow on the affected side with a bowing of the spine towards the opposite side; (6) pyelogram in lesions of appreciable size could not be differentiated from that of a neoplasm, showing the characteristic filling defect or compression type of pelvic and caliceal distortion. Case 1. A white male, aged 26, entered the Englewood Hospital on July 17, 1928, complaining of pain in the left lumbar region which had been present for several weeks. The man was not acutely ill but was running a low-grade temperature with a persistent leucocytosis ranging from 9 to 11,000. Urine examination was entirely negative. He gave a history of having a cutaneous suppurative lesion on his left forearm 4 weeks prior to beginning of lumbar pain. Cystoscopic examination gave no additional information. A diagnosis of left perinephric abscess was made and surgical interference advised, but the patient refused surgery. At home he was constantly conscious of distress in his left lumbar region and had a daily elevation of temperature. He returned to the hospital 4 weeks later. He showed evidence of a chronic sepsis with some degree of secondary anemia and a leucocytosis of 12,000. Physical examination revealed a board-like hardness and tenderness in the left costovertebral angle. Surgical interference was carried out. A carbuncle about 3 cm. in diameter was found on the posterior surface of the upper pole of the left kidney which was curetted and packed. Marked perinephric reaction was present but no associated perinephric abscess. Convalescence was slow and patient left hospital 8 weeks after date of first admission. Case 2. A white female, aged 20, was admitted to Holy Cross Hospital on June 10, 1929 with a diagnosis of subacute appendicitis. Two weeks prior to admission to hospital, following a game of tennis, she began to have a dull, aching pain in the epigastrium which became diffuse but did not at any time localize in the right lower quadrant. The pain was not severe enough to prevent her working but she did tire easily and was constantly conscious of abdominal discomfort. Her temperature was 100.2, pulse 94, respirations 20.
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The only physical finding elicited was a diffuse abdominal tenderness. Urine was entirely negative. Leucocyte count was 13,500. On the following day an exploratory laparotomy was performed, removing a normal appendix and a right cystic ovary. The postoperative course was not that of a usual uncomplicated laparotomy. She continued to have an elevation of temperature and developed a constant dull pain in the left lumbar region. Abdomen remained soft, there being no evidence of peritonitis. The leucocyte count remained high and on the seventeenth postoperative day was
FIG. 1. Case 3.
Showing obliteration right psoas outline and bowing of spine
31,450. Because of the persistent lumbar pain, urological consultation was requested on the nineteenth postoperative day. The patient presented the following picture: general appearance of a severe sepsis; temperature 103.6; pulse 110; recent abdominal incision entirely healed; definite tenderness and resistance over the left renal angle. Cystoscopy gave no additional information. A flat x-ray film of the abdomen revealed obliteration of the left psoas shadow with a bowing of the spine to the right. A left retrograde pyelogram appeared normal. Bladder urine and specimens of urine from each kidney were negative.
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Further questioning of the patient elicited a history of furuncle in front of the right ear 3 weeks before onset of abdominal symptoms. A diagnosis of carbuncle of the left kidney was made. On the twentieth postoperative day an exploratory operation revealed a carbuncle on the anterior surface of the left kidney which was curetted and packed. Culture of pus yielded a pure growth of Staphylococcus aureus. Case 3. A white male, aged 28, entered St. Bernard's Hospital March 4, 1930 on the service of Dr. William Gunn for diagnostic study. Onset of the
FIG. 2. Case 3. capsule.
Note carbuncle involving upper pole with thickened adherent fatty
present trouble dated back 4 weeks to a cutaneous suppurative lesion over right scapula which was incised and drained. Right costovertebral pain began 3 weeks after drainage of cutaneous lesion. The pain was constant in character with no radiation and was exaggerated by deep inspiration. Fever, malaise and loss of weight accompanied lumbar pain. Tenderness with some slight fullness was present in the right costal angle. Urine showed a trace of albumin and the leucocyte count was 21,600. X-ray of the chest was negative. A
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flat x-ray film of the abdomen showed obliteration of right psoas and bowing of spine towards left side. A diagnosis of perinephric abscess secondary to a cortical renal infection was made and surgery advised. On March 12, 1930 a large perinephric abscess was drained. A carbuncle was found involving the upper pole of the kidney which was curetted and packed. On the ninth postoperative day because of an increasing sepsis associated with daily rising temperature and a persistent high leucocytosis a right nephrectomy was performed. Cultures of pus on each occasion yielded a growth of Staphylococcus aureus. Pathological report (Dr. Chester Guy): Carbuncle of the kidney. Convalescence was very slow. Patient had a persistent rapid pulse due to myocardial damage. He left the hospital 42 days after the nephrectomy and was bed-ridden for three months. Case 4. A white male, aged 26, entered the Evangelical Deaconess Hospital on September 21, 1932 complaining of pain in left lumbar region which had been present for 2 weeks. Two weeks prior to onset of lumbar pain a boil had been incised on the right forearm. Findings on admission were: temperature 101, pulse 98. Essential physical findings were tenderness over left costovertebral angle with a marked increase in resistance to deep pressure with no fullness. Urine was negative; leucocyte count 33,800. A diagnosis of carbuncle of the left kidney was made on the basis of history, clinical findings, in association with x-ray evidence of an enlarged kidney shadow, obliteration of left psoas outline and a pyelogram with an irregular filling defect. On the day following admission surgical interference was carried out. Two distinct carbuncles of the left kidney were found. The fatty capsule was thickened and very adherent to kidney in region of carbuncles. Each lesion was curetted and packed with iodoform gauze. Postoperatively the patient became steadily more septic. Daily temperature reached 104 with continued elevation of leucocyte count. On the eleventh postoperative day a nephrectomy was thought advisable. This was done and immediate improvement in patient's condition followed. In 6 days his temperature had returned to normal and his general condition appeared good. He was discharged from the hospital on the tenth postoperative day. Ten days after leaving the hospital he developed a left lower bronchopneumonia which terminated 4 weeks later in a cerebrospinal meningitis. Culture of spinal fluid yielded Staphylococcus aureus. He died 3 months after initial symptoms appeared. Pathological report of kidney (Dr. P. Delaney): Multiple carbuncles of left kidney. Case 5. A male patient, aged 39, was referred on March 7, 1933 by Dr. C. Shallot for study. The patient complained of a dull, aching pain in right lumbar region present for a week and associated with chills and fever. No urinary
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symptoms were present. He gave a history of having a series of small boils 5 weeks previous to admission, several of which had been incised. Regional examination was negative except for tenderness and board-like resistance over right costovertebral angle. The urine showed a trace of albumin and the leucocyte count was 16,000. A series of intravenous urograms were taken, the findings of which in conjunction with the clinical picture led to a diagnosis of carbuncle of the kidney. This diagnosis was confirmed by the surgical findings. The right kidney was removed.
FIG. 3. Case 5.
Note carbuncle involving middle zone of kidney
Pathological report of right kidney (Dr. P. Delaney): Carbuncle of the kidney. Case 6. A white female, aged 52, entered St. Bernard's Hospital November 11, 1933 complaining of pain in the right upper abdomen, frequency of urination and nocturia all of which began 1 year previous to admission but had increased in severity during the past 4 weeks. Her symptoms did not become pronounced enough to warrant consulting a doctor until following a "cold" which started with a chill, they became very noticeable. The pain localized in the right lumbar region and was dull, aching and constant in character and was associated with an increase of bladder symptoms and marked loss of weight.
332
FIG. 4. Case 6. neoplasm.
FrG. 5. Case 6.
GEORGE A. INGRISH
Retrograde pyelogram, showing filling defect easily confused with
Note carbuncle with tremendously thickened leathery fatty capsule
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On examination a mass was palpated which appeared to be an enlarged right kidney. Urine contained many pus cells and a trace of albumin. Intravenous urograms revealed a normal left kidney. TheTight pyelogram was not conclusive, necessitating a retrograde pyelogram, from which a diagnosis was made of an infected right renal neoplasm, and surgery was advised. A right nephrectomy was carried out, removing the kidney with a thickened, adherent, fatty capsule. No gross pus was found in the perinephric space. Pathological report of right kidney (Dr. C. Guy): Carbuncle of the kidney.
FIG. 6. Case 7.
Showing obliteration of right psoas outline and bowing of spine
Following operation it was discovered that S weeks prior to admission to the hospital, the patient had a boil above her right eye. Case 7. A white male, aged 45, entered the Englewood Hospital on June 30, 1933 on the medical service of Dr. Wm. Gregg, complaining of pain in the right mid-axillary line midway between costal arch and crest of ileum, associated with a temperature of 103 and a feeling of chilliness. These symptoms had been present for S days with gradually increasing severity. The patient recalled a series of boils on the back of his neck 3 weeks prior to admission to hospital. The only physical finding was a right costovertebral tenderness and board-like resistance. Urine was normal; leucocyte count 17,450. A series
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of intravenous urograms revealed obliteration of the right psoas with an increase in size of kidney shadow and a bowing of spine to the left. Left pyelogram was normal. Excretion was delayed on the right with compression of upper major calyx. A diagnosis of right renal carbuncle was made. The patient refused surgery, remaining at bed rest in hospital for 6 days. His temperature and leucocyte
Frc. 7. Case 7.
Note carbuncle involving upper pole of kidney
count gradually approached normal. He was then discharged. At home he had a daily elevation of temperature and began to lose weight and feel very weak. He returned to the hospital 7 days later for surgical interference. Operative findings were that of a carbuncle involving upper pole of kidney. Kidney with adherent, thickened, leathery, fatty capsule was removed.
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Pathological report of right kidney (Dr. P. Delaney): Carbuncle of kidney. Culture of pus yielded Staphylococcus aureus. Case 8. A white female, aged 64, entered the Evangelical Hospital on August 5, 1934 on the service of Dr. A. G. Johnson complaining of severe pain in right upper quadrant and lumbar region for 3 weeks associated with nocturia and frequency of urination. Nausea and vomiting began 4 days prior to admission to hospital. Past history was essentially negative. A mass was found in right upper quadrant which appeared to be an enlarged right kidney. Urine was negative; leucocyte count 17,800. A retrograde pyelogram revealed
FIG.
8. Case 8.
Retrograde pyelogram, showing compression of upper major calyx
a filling defect suggestive of a tumor. A diagnosis of neoplasm of right kidney was made and kidney was removed at operation. Pathological report of right kidney (Dr. P. Delaney): Multiple carbuncles of kidney. Culture of pus yielded Staphylococcus aureus. The patient left the operating room in moderate shock from which she failed to rally and expired on the second postoperative day. Case 9. A female, aged 23, entered the Woodlawn Hospital on August 20, 1934 on the service of Dr. Walter Coen, complaining of pain in the left lower abdomen which was sharp and stabbing in character, aggravated by coughing and deep breathing. The pain gradually shifted and became localized in the
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right dorso-lumbar region. No urinary symptoms were present. Two weeks prior to onset of present illness she had had a boil on her cheek incised. Physical examination disclosed left lumbar rigidity and tenderness. No fullness was present. Intravenous urograms were essentially negative. Urine was normal; leucocyte count 16,000. Operative findings 2 days after admission revealed a thickened, leathery, fatty capsule with a small carbuncle on the anterior surface of the kidney which was curetted and packed. Postoperative convalescence was uneventful.
FIG. 9. Case 8.
Showing multiple carbuncles of the kidney
Case 10. A white female, aged 20, entered Holy Cross Hospital March 27, 1938 on the service of Dr. S. Biezis complaining of high temperature for 4 weeks, pain in right side for 6 weeks and weakness. She had been confined to her bed at home by another physician and because of a weakly positive Widal test a diagnosis of typhoid fever had been considered. Patient had had many boils since and during adolescence, the last one being on her chin 3 weeks prior to onset of present trouble. No urinary symptoms were present. Physical findings: A diffuse abdominal tenderness with extreme rigidity of right renal angle. No other findings were present. The patient appeared very septic. Occasional pus cells were found in the urine; leucocyte count 19,400. Intravenous urograms showed a large filling defect in middle third of kidney which
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FIG. 10. Case 10. Intravenous pyelogram, showing compression of middle and lower major calices which could be confused with neoplasm.
FIG. 11. Case 10.
Note carbuncle involving middle two-thirds of kidney
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GEORGE A. INGRISH
combined with clinical picture led to a diagnosis of carbuncle of the kidney. A right nephrectomy confirmed this diagnosis. Pathological report (Dr. C. Hospers): Large carbuncle of kidney involving the middle third of cortex and medulla. Culture of pus yielded Staphylococcus aureus. The following case is included in this report but is not classed as a true carbuncle. Inasmuch as the clinical and x-ray findings make it impossible to differentiate it from a carbuncle of the kidney and because of
FIG: 12. Case 11. Intravenous urogram, showing enlarged right kidney, obliteration psoas outline and bowing of spine. Calices dilated and blunted.
the relative rarity of the disease it has been included rather than submitted as a separate report. Case 11. A white female, aged 17, entered the Burnside Hospital March 20, 1938, complaining of pain in the right side associated with some nausea and occasional vomiting. Temperature was 101; leucocyte count 14,000. No urinary symptoms were present. A diagnosis of acute appe~dicitis was made. On operation a normal appendix was removed. On exploration of the abdomen an enlarged kidney was felt. The postoperative course was grave. The patient became more septic and seemed to be rapidly losing ground. Urological consultation was requested to determine whether or not cystoscopy was indicated for a more accurate diagnosis. However, on the findings of a flat film and a series of intravenous urograms, a diagnosis of carbuncle of the kidney was made. The patient's mother recalled that 3 weeks prior to onset
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of abdominal pain the patient had had several large furuncles on her forehead. Surgical exploration revealed a typical Brewer's kidney (focal suppurative nephritis), which was removed. Pathological report, right kidney, (Dr. C. Hospers) confirmed the above diagnosis. Culture of the pus yielded Staphylococcus aureus.
FIG. 13. Case 11.
Shmving diffuse suppurative nephritis (Brewer's kidney) CONCLUSIONS
Eleven cases of metastatic staphylococcus infection of the kidney, proven by operation, have been reported. From a review of these cases, I find several certain salient facts regarding the etiology, symptoms, diagnosis and management which I consider worthy of special emphasis. The primary focus in each of the 11 cases was a cutaneous suppurative lesion of no certain location. The organism isolated from the involved kidney was a Staphylococcus aureus. A rather diagnostic physical sign demonstrated by Dr. Frank M. Phifer, which has not been emphasized by other writers, is a stony hard costo-vertebral rigidity on the affected side. This is due to a tremendous perinephric reaction and a marked thickening of the fatty capsule which becomes leathery in character. Fullness over the renal angle is characteristically absent except in cases having an associated perinephric abscess. The urine in the majority of the cases was characteristically normal
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except for a slight trace of albumin which was undoubtedly on the basis of a toxic nephritis. Intravenous urography in conjunction with the careful interpretation of a flat x-ray film, when localizing symptoms are present, and a history of a recent cutaneous lesion, will usually suffice to make a diagnosis. Cystoscopy is seldom indicated. Inasmuch as the pyelographic findings in 2 of the 11 reported cases could not be differentiated from that of a neoplasm, it is important to include carbuncle in the differential diagnosis in which a diagnosis of tumor of the kidney is made when the patient is showing evidence of sepsis. Lesions on the anterior surface of the kidney are associated with abdominal symptoms which at times lead to an erroneous diagnosis of intra-abdominal diseases. Considerable confusion and differences of opinion exist in the literature as to treatment. Inasmuch as conservative treatment with incision and drainage failed to affect a cure in 2 of these cases, it is felt that the toxic patient, especially if more than one lesion on the kidney is present, should be subjected to nephrectomy rather than to some form of conservative surgery. The postoperative management of these patients is important inasmuch as they show evidence of myocardial damage due to the prolonged and severe sepsis and for that reason they should be kept at bed rest until the pulse approaches normal. Also, general measures to increase the resistance of the patient should be carried out.
6156 Evans Ave., Chicago, Ill. REFERENCES BANGERTER, J.: Schwerz Med. Wchnschr., 67: 310-312, 1937. BEER, E.: J. A. M.A., 106: 1063-1070, 1936. - - ~ : Abstr. J. Urol., 35: 491-493, 1936. BRADY, L.: J. Urol., 27: 295-316, 1932. CIBERT, J. AND KLAJMAN, H.: J. d'urol., 44: 273, 353, 1937. DAVIDSON, B.: Urol. and Cutan. Rev., 40: 260-262, 1936. DROSCHL, H.: Zeutsaebl f. Chu. 64: 1209-1212, 1937. EMMETT, J. L., AND PRIESTLEY, J. T.: Proc. Staff Meet., Mayo Clin. 11: 764-767, 1936. GRAVES, R. C. AND PARKINS, L. E.: Tr. Am. A. Genito-Urin. Surgeons, 28: 41-76, 1935 J. Urol. 35: 1-14, 1936. GROSSMAN, S. L.: Pennsylvania M. J., 41: 495-500, 1938. HAMER, H. G.: J. Urol., 38: 530-540, 1937. HERZOA, A. AND ALT, L.: Ztschr. f. Urol. 31: 807-810, 1937. KRETSCHMER, H. L.: J. Urol. 8: 137-148, 1922. LAZARUS, J. A.: J. Urol. 21: 353-362, 1929. LuccroNI, C.: Rinasc. Med.14: 556-559, 1937. MATHE, C. P.: Tr. Sect. Urol., A. M.A. pp. 49-71, 1929. McNuLTY, P.H.: J. Urol. 35: 15-20, 1936. O'CoNOR, V. J.: J. Urol. 30: 1-13, 1933. TAYLOR, WM. N.: Am. J. Surg. 22: 550-556, 1933. WOODRUFF, S. R. AND GROSSMAN, S. L.: Urol. and Cutan. Rev. 40: 240-244, 1936.
Carbuncle of the kidney may be defined in the light of our present knowledge as one stage of a progressive pathological process in which a localized metastatic staphylococcic nephritis has progressed to a walledoff coalescence of multiple cortical abscesses. According to most writers, Israel described the first case of carbuncle of the kidney in 1891. Since then approximately 120 papers on this subject have appeared in the literature, reporting a total of 136 cases. The increase in the number of reported cases in the past 10 years speaks more for a greater accuracy in diagnosis than an increase in the incidence of this true clinical entity. A brief summary of the 136 cases appearing in the literature followed by a more detailed description of an additional 10 unreported cases from the private urological practice of Dr. Frank M. Phifer is herewith presented. Sex: Male cases reported-84; female cases reported-32; sex not recorded-20. Primary foci in order of frequency: Cutaneous carbuncle; furunculosis; cellulitis; paronychia; and osteomyelitis. Causative Organism: Staphylococcus aureus-98; Staphylococcus albus-6; mixed infection-10; not recorded-22. Number and location of Carbuncle: Unilateral-110; bilateral-4; single lesions-104; multiple lesions-32; right side-86; left side-SO; associated with a perinephritic abscess-14. Treatment: There appears to be considerable variation of opinion as to the proper surgical procedure, varying from decapsulation of the kidney with incision, curettment and drainage (Beer), excision, to partial or complete nephrectomy. There is also a group of men who have advocated medical management, consisting of antiphlogistic measures, use of vaccines and deep x-ray therapy. They base their contention for this line of treatment on the fact that many postmortem findings show evidence of apparently healed cortical lesions. A complete discussion of the literature would be superfluous, as several authors (Graves and Parkins, and others) recently reported this subject in detail. It is felt that a brief report of the following cases would be of some value, as an accurate preoperative diagnosis was made in all but 2 cases. 1
Read before Chicago Urological Association February 1938. 326
CARBUNCLE OF KIDNEY
327
In making a diagnosis of carbuncle the following characteristic :findings were present in all cases: (1) gradual onset of fever, chills, malaise, associated with lumbar or abdominal pain; (2) physical :findings: a varying degree of tenderness with a stony hard, flat, costovertebral rigidity, this in all probability being due to the thickened, leathery, fatty capsule. Costovertebral fullness was only present in those cases with an associated perinephric abscess; (3) history of some form of cutaneous suppuration, occurring from 2 weeks to 2 months preceding renal symptoms; (4) urine was essentially negative in most cases; (5) x-ray examination usually revealed an obliteration of psoas shadow on the affected side with a bowing of the spine towards the opposite side; (6) pyelogram in lesions of appreciable size could not be differentiated from that of a neoplasm, showing the characteristic filling defect or compression type of pelvic and caliceal distortion. Case 1. A white male, aged 26, entered the Englewood Hospital on July 17, 1928, complaining of pain in the left lumbar region which had been present for several weeks. The man was not acutely ill but was running a low-grade temperature with a persistent leucocytosis ranging from 9 to 11,000. Urine examination was entirely negative. He gave a history of having a cutaneous suppurative lesion on his left forearm 4 weeks prior to beginning of lumbar pain. Cystoscopic examination gave no additional information. A diagnosis of left perinephric abscess was made and surgical interference advised, but the patient refused surgery. At home he was constantly conscious of distress in his left lumbar region and had a daily elevation of temperature. He returned to the hospital 4 weeks later. He showed evidence of a chronic sepsis with some degree of secondary anemia and a leucocytosis of 12,000. Physical examination revealed a board-like hardness and tenderness in the left costovertebral angle. Surgical interference was carried out. A carbuncle about 3 cm. in diameter was found on the posterior surface of the upper pole of the left kidney which was curetted and packed. Marked perinephric reaction was present but no associated perinephric abscess. Convalescence was slow and patient left hospital 8 weeks after date of first admission. Case 2. A white female, aged 20, was admitted to Holy Cross Hospital on June 10, 1929 with a diagnosis of subacute appendicitis. Two weeks prior to admission to hospital, following a game of tennis, she began to have a dull, aching pain in the epigastrium which became diffuse but did not at any time localize in the right lower quadrant. The pain was not severe enough to prevent her working but she did tire easily and was constantly conscious of abdominal discomfort. Her temperature was 100.2, pulse 94, respirations 20.
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The only physical finding elicited was a diffuse abdominal tenderness. Urine was entirely negative. Leucocyte count was 13,500. On the following day an exploratory laparotomy was performed, removing a normal appendix and a right cystic ovary. The postoperative course was not that of a usual uncomplicated laparotomy. She continued to have an elevation of temperature and developed a constant dull pain in the left lumbar region. Abdomen remained soft, there being no evidence of peritonitis. The leucocyte count remained high and on the seventeenth postoperative day was
FIG. 1. Case 3.
Showing obliteration right psoas outline and bowing of spine
31,450. Because of the persistent lumbar pain, urological consultation was requested on the nineteenth postoperative day. The patient presented the following picture: general appearance of a severe sepsis; temperature 103.6; pulse 110; recent abdominal incision entirely healed; definite tenderness and resistance over the left renal angle. Cystoscopy gave no additional information. A flat x-ray film of the abdomen revealed obliteration of the left psoas shadow with a bowing of the spine to the right. A left retrograde pyelogram appeared normal. Bladder urine and specimens of urine from each kidney were negative.
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Further questioning of the patient elicited a history of furuncle in front of the right ear 3 weeks before onset of abdominal symptoms. A diagnosis of carbuncle of the left kidney was made. On the twentieth postoperative day an exploratory operation revealed a carbuncle on the anterior surface of the left kidney which was curetted and packed. Culture of pus yielded a pure growth of Staphylococcus aureus. Case 3. A white male, aged 28, entered St. Bernard's Hospital March 4, 1930 on the service of Dr. William Gunn for diagnostic study. Onset of the
FIG. 2. Case 3. capsule.
Note carbuncle involving upper pole with thickened adherent fatty
present trouble dated back 4 weeks to a cutaneous suppurative lesion over right scapula which was incised and drained. Right costovertebral pain began 3 weeks after drainage of cutaneous lesion. The pain was constant in character with no radiation and was exaggerated by deep inspiration. Fever, malaise and loss of weight accompanied lumbar pain. Tenderness with some slight fullness was present in the right costal angle. Urine showed a trace of albumin and the leucocyte count was 21,600. X-ray of the chest was negative. A
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flat x-ray film of the abdomen showed obliteration of right psoas and bowing of spine towards left side. A diagnosis of perinephric abscess secondary to a cortical renal infection was made and surgery advised. On March 12, 1930 a large perinephric abscess was drained. A carbuncle was found involving the upper pole of the kidney which was curetted and packed. On the ninth postoperative day because of an increasing sepsis associated with daily rising temperature and a persistent high leucocytosis a right nephrectomy was performed. Cultures of pus on each occasion yielded a growth of Staphylococcus aureus. Pathological report (Dr. Chester Guy): Carbuncle of the kidney. Convalescence was very slow. Patient had a persistent rapid pulse due to myocardial damage. He left the hospital 42 days after the nephrectomy and was bed-ridden for three months. Case 4. A white male, aged 26, entered the Evangelical Deaconess Hospital on September 21, 1932 complaining of pain in left lumbar region which had been present for 2 weeks. Two weeks prior to onset of lumbar pain a boil had been incised on the right forearm. Findings on admission were: temperature 101, pulse 98. Essential physical findings were tenderness over left costovertebral angle with a marked increase in resistance to deep pressure with no fullness. Urine was negative; leucocyte count 33,800. A diagnosis of carbuncle of the left kidney was made on the basis of history, clinical findings, in association with x-ray evidence of an enlarged kidney shadow, obliteration of left psoas outline and a pyelogram with an irregular filling defect. On the day following admission surgical interference was carried out. Two distinct carbuncles of the left kidney were found. The fatty capsule was thickened and very adherent to kidney in region of carbuncles. Each lesion was curetted and packed with iodoform gauze. Postoperatively the patient became steadily more septic. Daily temperature reached 104 with continued elevation of leucocyte count. On the eleventh postoperative day a nephrectomy was thought advisable. This was done and immediate improvement in patient's condition followed. In 6 days his temperature had returned to normal and his general condition appeared good. He was discharged from the hospital on the tenth postoperative day. Ten days after leaving the hospital he developed a left lower bronchopneumonia which terminated 4 weeks later in a cerebrospinal meningitis. Culture of spinal fluid yielded Staphylococcus aureus. He died 3 months after initial symptoms appeared. Pathological report of kidney (Dr. P. Delaney): Multiple carbuncles of left kidney. Case 5. A male patient, aged 39, was referred on March 7, 1933 by Dr. C. Shallot for study. The patient complained of a dull, aching pain in right lumbar region present for a week and associated with chills and fever. No urinary
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symptoms were present. He gave a history of having a series of small boils 5 weeks previous to admission, several of which had been incised. Regional examination was negative except for tenderness and board-like resistance over right costovertebral angle. The urine showed a trace of albumin and the leucocyte count was 16,000. A series of intravenous urograms were taken, the findings of which in conjunction with the clinical picture led to a diagnosis of carbuncle of the kidney. This diagnosis was confirmed by the surgical findings. The right kidney was removed.
FIG. 3. Case 5.
Note carbuncle involving middle zone of kidney
Pathological report of right kidney (Dr. P. Delaney): Carbuncle of the kidney. Case 6. A white female, aged 52, entered St. Bernard's Hospital November 11, 1933 complaining of pain in the right upper abdomen, frequency of urination and nocturia all of which began 1 year previous to admission but had increased in severity during the past 4 weeks. Her symptoms did not become pronounced enough to warrant consulting a doctor until following a "cold" which started with a chill, they became very noticeable. The pain localized in the right lumbar region and was dull, aching and constant in character and was associated with an increase of bladder symptoms and marked loss of weight.
332
FIG. 4. Case 6. neoplasm.
FrG. 5. Case 6.
GEORGE A. INGRISH
Retrograde pyelogram, showing filling defect easily confused with
Note carbuncle with tremendously thickened leathery fatty capsule
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On examination a mass was palpated which appeared to be an enlarged right kidney. Urine contained many pus cells and a trace of albumin. Intravenous urograms revealed a normal left kidney. TheTight pyelogram was not conclusive, necessitating a retrograde pyelogram, from which a diagnosis was made of an infected right renal neoplasm, and surgery was advised. A right nephrectomy was carried out, removing the kidney with a thickened, adherent, fatty capsule. No gross pus was found in the perinephric space. Pathological report of right kidney (Dr. C. Guy): Carbuncle of the kidney.
FIG. 6. Case 7.
Showing obliteration of right psoas outline and bowing of spine
Following operation it was discovered that S weeks prior to admission to the hospital, the patient had a boil above her right eye. Case 7. A white male, aged 45, entered the Englewood Hospital on June 30, 1933 on the medical service of Dr. Wm. Gregg, complaining of pain in the right mid-axillary line midway between costal arch and crest of ileum, associated with a temperature of 103 and a feeling of chilliness. These symptoms had been present for S days with gradually increasing severity. The patient recalled a series of boils on the back of his neck 3 weeks prior to admission to hospital. The only physical finding was a right costovertebral tenderness and board-like resistance. Urine was normal; leucocyte count 17,450. A series
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GEORGE A. INGRISH
of intravenous urograms revealed obliteration of the right psoas with an increase in size of kidney shadow and a bowing of spine to the left. Left pyelogram was normal. Excretion was delayed on the right with compression of upper major calyx. A diagnosis of right renal carbuncle was made. The patient refused surgery, remaining at bed rest in hospital for 6 days. His temperature and leucocyte
Frc. 7. Case 7.
Note carbuncle involving upper pole of kidney
count gradually approached normal. He was then discharged. At home he had a daily elevation of temperature and began to lose weight and feel very weak. He returned to the hospital 7 days later for surgical interference. Operative findings were that of a carbuncle involving upper pole of kidney. Kidney with adherent, thickened, leathery, fatty capsule was removed.
CARBUNCLE OF KIDNEY
335
Pathological report of right kidney (Dr. P. Delaney): Carbuncle of kidney. Culture of pus yielded Staphylococcus aureus. Case 8. A white female, aged 64, entered the Evangelical Hospital on August 5, 1934 on the service of Dr. A. G. Johnson complaining of severe pain in right upper quadrant and lumbar region for 3 weeks associated with nocturia and frequency of urination. Nausea and vomiting began 4 days prior to admission to hospital. Past history was essentially negative. A mass was found in right upper quadrant which appeared to be an enlarged right kidney. Urine was negative; leucocyte count 17,800. A retrograde pyelogram revealed
FIG.
8. Case 8.
Retrograde pyelogram, showing compression of upper major calyx
a filling defect suggestive of a tumor. A diagnosis of neoplasm of right kidney was made and kidney was removed at operation. Pathological report of right kidney (Dr. P. Delaney): Multiple carbuncles of kidney. Culture of pus yielded Staphylococcus aureus. The patient left the operating room in moderate shock from which she failed to rally and expired on the second postoperative day. Case 9. A female, aged 23, entered the Woodlawn Hospital on August 20, 1934 on the service of Dr. Walter Coen, complaining of pain in the left lower abdomen which was sharp and stabbing in character, aggravated by coughing and deep breathing. The pain gradually shifted and became localized in the
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GEORGE A. INGRISH
right dorso-lumbar region. No urinary symptoms were present. Two weeks prior to onset of present illness she had had a boil on her cheek incised. Physical examination disclosed left lumbar rigidity and tenderness. No fullness was present. Intravenous urograms were essentially negative. Urine was normal; leucocyte count 16,000. Operative findings 2 days after admission revealed a thickened, leathery, fatty capsule with a small carbuncle on the anterior surface of the kidney which was curetted and packed. Postoperative convalescence was uneventful.
FIG. 9. Case 8.
Showing multiple carbuncles of the kidney
Case 10. A white female, aged 20, entered Holy Cross Hospital March 27, 1938 on the service of Dr. S. Biezis complaining of high temperature for 4 weeks, pain in right side for 6 weeks and weakness. She had been confined to her bed at home by another physician and because of a weakly positive Widal test a diagnosis of typhoid fever had been considered. Patient had had many boils since and during adolescence, the last one being on her chin 3 weeks prior to onset of present trouble. No urinary symptoms were present. Physical findings: A diffuse abdominal tenderness with extreme rigidity of right renal angle. No other findings were present. The patient appeared very septic. Occasional pus cells were found in the urine; leucocyte count 19,400. Intravenous urograms showed a large filling defect in middle third of kidney which
CARBUNCLE OF KIDNEY
337
FIG. 10. Case 10. Intravenous pyelogram, showing compression of middle and lower major calices which could be confused with neoplasm.
FIG. 11. Case 10.
Note carbuncle involving middle two-thirds of kidney
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GEORGE A. INGRISH
combined with clinical picture led to a diagnosis of carbuncle of the kidney. A right nephrectomy confirmed this diagnosis. Pathological report (Dr. C. Hospers): Large carbuncle of kidney involving the middle third of cortex and medulla. Culture of pus yielded Staphylococcus aureus. The following case is included in this report but is not classed as a true carbuncle. Inasmuch as the clinical and x-ray findings make it impossible to differentiate it from a carbuncle of the kidney and because of
FIG: 12. Case 11. Intravenous urogram, showing enlarged right kidney, obliteration psoas outline and bowing of spine. Calices dilated and blunted.
the relative rarity of the disease it has been included rather than submitted as a separate report. Case 11. A white female, aged 17, entered the Burnside Hospital March 20, 1938, complaining of pain in the right side associated with some nausea and occasional vomiting. Temperature was 101; leucocyte count 14,000. No urinary symptoms were present. A diagnosis of acute appe~dicitis was made. On operation a normal appendix was removed. On exploration of the abdomen an enlarged kidney was felt. The postoperative course was grave. The patient became more septic and seemed to be rapidly losing ground. Urological consultation was requested to determine whether or not cystoscopy was indicated for a more accurate diagnosis. However, on the findings of a flat film and a series of intravenous urograms, a diagnosis of carbuncle of the kidney was made. The patient's mother recalled that 3 weeks prior to onset
CARBUNCLE OF KIDNEY
339
of abdominal pain the patient had had several large furuncles on her forehead. Surgical exploration revealed a typical Brewer's kidney (focal suppurative nephritis), which was removed. Pathological report, right kidney, (Dr. C. Hospers) confirmed the above diagnosis. Culture of the pus yielded Staphylococcus aureus.
FIG. 13. Case 11.
Shmving diffuse suppurative nephritis (Brewer's kidney) CONCLUSIONS
Eleven cases of metastatic staphylococcus infection of the kidney, proven by operation, have been reported. From a review of these cases, I find several certain salient facts regarding the etiology, symptoms, diagnosis and management which I consider worthy of special emphasis. The primary focus in each of the 11 cases was a cutaneous suppurative lesion of no certain location. The organism isolated from the involved kidney was a Staphylococcus aureus. A rather diagnostic physical sign demonstrated by Dr. Frank M. Phifer, which has not been emphasized by other writers, is a stony hard costo-vertebral rigidity on the affected side. This is due to a tremendous perinephric reaction and a marked thickening of the fatty capsule which becomes leathery in character. Fullness over the renal angle is characteristically absent except in cases having an associated perinephric abscess. The urine in the majority of the cases was characteristically normal
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GEORGE A. INGRISH
except for a slight trace of albumin which was undoubtedly on the basis of a toxic nephritis. Intravenous urography in conjunction with the careful interpretation of a flat x-ray film, when localizing symptoms are present, and a history of a recent cutaneous lesion, will usually suffice to make a diagnosis. Cystoscopy is seldom indicated. Inasmuch as the pyelographic findings in 2 of the 11 reported cases could not be differentiated from that of a neoplasm, it is important to include carbuncle in the differential diagnosis in which a diagnosis of tumor of the kidney is made when the patient is showing evidence of sepsis. Lesions on the anterior surface of the kidney are associated with abdominal symptoms which at times lead to an erroneous diagnosis of intra-abdominal diseases. Considerable confusion and differences of opinion exist in the literature as to treatment. Inasmuch as conservative treatment with incision and drainage failed to affect a cure in 2 of these cases, it is felt that the toxic patient, especially if more than one lesion on the kidney is present, should be subjected to nephrectomy rather than to some form of conservative surgery. The postoperative management of these patients is important inasmuch as they show evidence of myocardial damage due to the prolonged and severe sepsis and for that reason they should be kept at bed rest until the pulse approaches normal. Also, general measures to increase the resistance of the patient should be carried out.
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