- Email: [email protected]
Carbuncle of the Kidney1
CARBUNCLE OF THE KIDNEY1 HERMAN L. KRETSCHMER Chicago Received for publication June 20, 1922
By carbuncle of the kidney is meant an infection of the kidney by staphylococci, secondary to an infection elsewhere by this organism, such as a carbuncle or felon, in which the lesion of the kidney has the gross appearance of a carbuncle as seen in other parts of the body. Although the term "carbuncle of the kidney" is not in general use, there is no doubt in my mind about its clinical entity. This term is not a new one but it is used very infrequently in describing this lesion, Barth, Eisendrath and Isreal having used this term in their writings on this subject. Carbuncle of the kidney should be differentiated from the acute septic or embolic kidney in which the entire organ is studded with small miliary abscesses, as well as from renal abscesses, either solitary or multiple. It is my opinion that a lesion may start as a carbuncle and the entire area involved undergo suppuration, resulting in the production of large abscesses, single or multiple. If an operation is done early, a picture of typical carbuncle is seen: but when operated upon late in the course of the disease, the picture of abscess, either single or multiple, is encountered. There can be no doubt that one form may merge into the other. This was clearly illustrated in case 2 reported in this paper, when at operation the lesions were typical of carbuncle, but months later, at autopsy, were those of abscess formation in the remaining kidney. Carbuncle of the kidney is a metastatic lesion being similar in its origin to the acute septic kidney and perinephritic abscess; which means that there is or was present a lesion elsewhere in the 1 Read at the annual meeting of the American Urological Association, Atlantic City, April 26 to 28, 1922.
137 THE JOURNAL OF UROLOGY, VOL. VIII, NO. 2
138
HERMAN L. KRETSCHMER
body from which point organisms were transplanted to the kidney via the blood-stream. Often this lesion is obvious; at times, however, it is not. The _patient fails, in a number of instances, to tell us of previous attacks of boils, for the reason that he does not think "they amounted to very much" or because he is well of them and has completely forgotten about them. Again, the lesion of the skin may have been so slight that it healed without the patient being aware of its existence, such as lesions between the toes, eczema, etc. Occasionally, even when a carbuncle has occurred, the attending physician may overlook the relationship between the carbuncle and the kidney lesion- to my mind a most significant fact. The predisposing lesions in the two cases ·reported in this paper, were an osteomyelitis of the last phalanx of the right thumb in one case and a carbuncle of the neck in the other case. Phemister has recently called attention to the importance of lesions of the skin in the production of acute osteomyelitis, emphasizing the fact that the skin as a focus is so often overlooked, often forgotten and just as often neglected. Having recently had two cases of carbuncle of the kidney under observation, one unilateral and the other bilateral, in which the primary foci were demonstrable, and since the literature of this country is not characterized by reports of numerous cases of this type, the following two cases may not be without interest. Case 1. Mrs. H., aged thirty-five. Referred by Dr. T . E. Roberts. Admitted to the Presbyterian Hospital, October 25, 1920. In March, 1920, seven months before coming under observation, the patient developed a felon of the right thumb which was incised. One month later a piece of necrotic bone was removed, and on April 27, while the thumb was still suppurating, she gave birthtoachild. About June 7 she experienced an acute pain in the left side, which remained localized. A physician made a diagnosis of prolapsed kidney and she was instructed to wear a pad. The pain was not associated with urination, was dull in character and constant since its onset. Abdominal colic was so intense that she was compelled to double up to get relief. Nausea about half an hour after eating. Frequency of urination; voided about five times during the day and once at night. Urine very brown in color.
CARBUNCLE OF THE KIDNEY
139
Physical examination. Head, neck, heart and lungs, negative. The left half of the abdomen, very prominent and full. In the upper left quadrant a large, hard, irregular mass was palpable, slightly movable upon respiration, and very tender on pressure. Pressure over the back produced a sharp pain, extending into the groin. The mass was compatible with an enlarged, tender kdiney. Both upper and lower poles were palpable. There was an old healed felon of the right thumb. Blood examination. 14,400 leucocytes and hemoglobin 75 per cent. X-ray examination. Negative for stone. Cystoscopy, October 26, 1920. Bladder and lireteral orifices normal. Right ureter catheterized easily and a flow of clear urine obtained. Left ureter easily catheterized but no flow obtained. Urine from the bladder and right ureter negative for pus cells. Cultures showed the right side sterile and colon bacilli in the bladder. Stains for tubercle bacilli were negative. A mixed phenolsulphonephthalein test showed an output of 58 per cent in thirty minutes. Operation, November 4, 1920. The usual oblique lumbar incision was made in the left side and the kidney exposed. The kidney was firmly bound down by thick adhesions and because of these it was difficult to free and deliver the kidney. The tissues around the kidney were somewhat edematous. Ureter was ligated and cut about 1 inch from the pelvis. The pedicle was clamped with two clamps and the kidney removed, then the pedicle was ligated and the clamps removed. Muscles were approximated with heavy gut and cigarette drains were left in place. Patient made an uneventful recovery. Gross description. The kidney was about one-third larger than normal and the anterior surface, in one or two places, irregularly nodular. On section the cortex was 6 mm. thick and retained its markings with the exception of several large abscesses, which contained thick, greenishyellow pus, situated mostly in the anterior half. In close proximity to the larger abscesses were seen several smaller areas that had the appearance of typical carbuncles. When these areas were pressed, thick, greenishyellow pus came to the surface. The posterior surface was smooth and the fibrous capsule very much thickened. The pelvis of the kidney was negative. Cultures of the pus from the abscesses showed hemolytic staphylococci. At the time the patient came under observation the felon had completely healed; hence it was not possible to obtain cultures to determine
·I 140
HERMAN L. KRETSCHMER
whether or not the organisms found in the kidney were identical with the organisms which produced the felon. Case 2. T. C. male, aged thirty-four. Referred by Dr. Weigan and Dr. Benson and admitted to the Presbyterian Hospital, September 15, 1921. During the first week in June, 1921, patient had a carbuncle of the neck which was incised and drained on June 11. When admitted to the hospital the carbuncle had completely healed. August 8, he complained of slight pain in the lower abdomen; perspiration profuse; temperature of 104.6°F. . He was admitted to another hospital where he remained until August 21, and then went home. August 29, his temperature rose suddenly to 102°F.; severenauseaand vomiting. Another attack of fever on September 3, at which time he first noticed that his urine was bloody. The hematuria lasted for three days and was associated with painful urination. Frequency of urination was also present; voided every one and one-half hours during the day and every two hours at night. Patient came under my observation on September 15. Physcial examination. Negative with the exception of the right kidney which was slightly enlarged and tender both in front and behind; some rigidity of the lumbar muscles. X-ray examination. Negative for stone. Blood chemistry. Sugar, 142.00 mgm., urea, 27.00 mgm., uric acid, 4.40 mgm., creatinin, 1.70 mgm., non protein nitrogen 43.00 mgm. Cystoscopy, September 20, 1921. Bladder and urteral orifices normal, and ureters were easily catheterized. Cell counts and cultures were as follows: CELLS (LEUCOCYTES)
Bladder .. . ... .. .... ..... . .. . . ..... . . Right kidney ......... . ..... .. . . .. . . . Left kidney .... ...... ... . .... . ..... .
10
130
60
CULTURES
Staphylococcus albus Sterile Sterile
Functional test. An output of 26 per cent from the right side and 20 per cent from the left side in thirty minutes. Blood examination, September 22, 1921. 16,800 leucocytes. Two Widal tests, negative. Cystoscopy, October 6, 1921. Bladder and ureteral orifices negative. From the left catheter a flow of golden yellow urine was obtained; from
141
CARBUNCLE OF THE KIDNEY
the right side, a very rapid flow of very pale urine, containing a large amount of pus shreds. Pyelogram. Twenty cubic centimeters of sodium bromide was injected into the right catheter. Pyelogram showed traces of the solution apparently extending from the twelfth dorsal to the second lumbar vertebra. Moderate dilatation of the right ureter with some deformity of the pelvis. Cell counts and cultures made at this time were as follows: CELLS
(LEUCOCYTES)
Bladder .... . . .. . ... . . . .. .. . . . . . .... . Right kidney . . . .. . .... . . .. .. . . . .. . . . Left kidney .... ... ... . . ... . .. .. .... .
110 1050
230
CULTURES
Staphylococcus aureus Staphylococcus aureus Sterile
Operation, October 11, 1921. The usual oblique lumbar incision was made over therightside; muscles and perirenalstructures very edematous ; fibrous capsule very thick and slightly edematous and much evidence of perinephritis; inflammatory thickening of the kidney pedicle. A large carbuncle, located nearly at the middle of the surface of the kidney, was noted. Two large clamps were placed on the pedicle, ligation with heavy catgut followed and the kidney was removed. At the end of forty-eight hours the clamps were removed. Gross description. The specimen is a large right kidney weighing 200 grams. It measures 13 by 6 by 4.5 cu. mm. The surfaces are smooth, glistening, and very dark red. Near the center of the posterior surface is a mass, somewhat nearer the upper than the lower pole. It is 4 by 3.5 cu. mm. and protrudes 0.5 cu. mm. from the surface. In this mass near the margin are six small swellings, red at the base with a white cap, each from 2 to 5 mm. in diameter. The cut surface of the kidney shows the cortex fairly pale, and in the medulla, at the center of the kidney, are many small, white opaque areas, irregular in form and irregularly distributed. They are all contained in an area 4 by 3 cu. mm. which corresponds to the swellings on the posterior surface. This shows many small isolated abscesses which upon cut surface has the gross appearance of a carbuncle seen, for example, on the back of the neck. Sectioning shows normal renal tissue, in certain parts of which are sharply demarcated regions, staining a faint blue and characterized chiefly by poorly staining fragmented nuclei and cytoplasm, the latter being quite granular and without cellular walls. A few polymorpho~
142
HERMAN L. KRETSCHMER
nuclear leucocytes are found in and around glomerular tufts and in the interspaces between the tubules. These tubules are filled with a bluestaining homogeneous material and the blood-vessels are engorged with red blood ·cells. A section from another portion of the kidney contains many polymorphonuclears distributed fairly uniformly throughout the entire section, some of them being in the lumen of the tubules among fragmented red blood cells. These tubules have rough epithelial walls due perhaps to partially desquamated eipthelium. Pus from the abscess showed cultures of pure staphylococcus aureus. Post-operative course. A moderate amount of shock followed the operation for which the patient was given rectal drip containing soda bicarbonate and 5 per cent glucose. Two ampules of digifolin were given by intramuscular injection. The drains were removed on the fourth day and small iodoform wicks placed in the wound. At the end of three weeks there was no discharge but the wound was kept open because the temperature persisted. Immediately after the operation the patient's temperature subsided so that it was normal in the morning and only 99.2°F. in the evening. This continued for about ten days when he again had a rise in temperature, going as high as 103°F. The temperature curve was very irregular. The amount of drainage from the wound being very scant and since there were no other findings to explain the temperature, the possibility of some deep-seated infection in the wound was discussed. The wound was reopened but no pus was found . The second operation did not influence the course of the temperature in any way and continued to vary from 98.8° to 102.4°F. We were particularly concerned with the cause of this continued high temperature and on November 17, Dr. Herrick was called in consultation. His findings follow: "Patient is pale. Heart enlarged to the left; a loud systolic murmur present, evidently of organic origin. Chest negative except for a few scattered rales at the right base, and anteriorly the hepatic dullness is 2 inches higher than normal. Abdominal examination, negative. No enlargement of the spleen. One or two doubtful petechial spots over the right arm and chest. " Examination by Dr. Herrick on November 26 showed patient less ill than at previous examination. The heart was the same as before. Another examination on December 15 showed heart and lung condition negative. The spleen was plainly palpable and there was a question whether or not the kidney was palpable.
143
CARBUNCLE OF THE KIDNEY
As the fever continued and as the patient had an organic heart murmur, the possibility of malignant endocarditis was considered and blood
cultures were made. During the course of three weeks, five sets of blood cultures were made, all of which were negative. The possibility of subphrenic abscess was also considered, but this was excluded by physical signs and roentgenograms. Since the temperature and leucocytosis could not be explained on the basis of infection elsewhere in the body, and taking into consideration the fact that the right kidney was removed for a carbuncle, the possibility of infection of the same type in the remaining kdiney was considered and strongly suspected. The various blood cultures, Widal tests and examinations for malaria were carried out, not so much with the object of finding some remote cause for the temperature as it was to exclude these causes. During the entire period of observation the urinary findings are of interest. Needless to state many urinalyses were made. After his nephrectomy all the urine voided was practically clear to the naked eye. Some of the reports showed a few leucocytes. Leucocytes per cu. mm .
November November December December December December December
29, 30, 5, 8, 11, 13, 14,
1921. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1921 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 1921 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 1921 .............. . ................. ... .. . ..... . .. Few 1921..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 1921 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1921 .... ....... ... ...... .. .. .. .. ... .. .. . . . ... ..... 110
An interesting point is the fact that though the patient was seriously ill, was running a high temperature and had a high leucocytosis, yet his urine was perfectly clear and the cell count showed only 30 to 110 pus cells per cu. mm. In one culture a few colonies of staphylococci were found. These were so few and the other cultures made before and after that particular culture being negative, a contamination was considered. The patient left the hospital on December 19, seemingly much improved. At the time of his dischargge the entire situation was again discussed and it was agreed that the cause of his high temperature and high leucocyte count was due to an infection in his remaining kidney and that in all probability it was of the same type as that found at operation in his opposite kidney, namely, carbuncle. The patient was readmitted to the hospital on January 20, 1922, with a small discharging sinus in his wound. After being at home for two
144
HERMAN L. KRETSCHMER
weeks he developed a superficial abscess of his nephrectomy wound from which about 3 ounces of pus were evacuated by Dr. Weigan. During the time he was at home he had an afternoon temperature varying from 101 ° to 103°F., and once he passed very bloody urine. Prior to the attack of hematuria his urine was clear. Immediately afterward large amounts of pus were found in every specimen examined. Apparently the carbuncle or abscess ruptured into the kidney pelvis since pus was constantly found after the hematuria. At the time of admission to the hospital patient's condition wss very critical. The left kidney was enlarged to about twice the size of a normal kidney. On January 28, his blood chemistry was as follows: Urea, 148.0 mgm., uric acid, 13.7 mgm., creatinin, 4.1 mgm., non-protein nitrogen 102.0 mgm. The patient gradually lost strength and died February 9, 1922. The autopsy was performed by Dr. Oberhelmen, pathologist to Presbyterian Hospital, and his report is as follows : "There is a large bulging mass in the left kidney region, larger than the open hand can cover, so that a part of each pole remains exposed. The spleen is huge and bound to the diaphragm behind by strands of fibrous adhesions. That part of the descending colon corresponding to the level of the left kidney is adherent to it by fibrous and fibrinous adhesions for 6 to 8 cm. up and down, and 1 to 2 cm. side to side. One small accidental cut is made into the kidney capsule and from this yellowish-green purulent fluid flows. "The left kidney is asymmetrical, the bulging being more in front than posteriorly. When cut into, thick, purulent, greenish-yellow pus escapes in a large amount. This pus is contained in small pockets, 3 to 10 mm. in diameter. These are surrounded by a grayish-yellow membrane 0.5 mm. thick. The broad surface made by sectioning these pus pockets, has a honeycomb appearance. These pus pockets involve all the kidney tissue for 8 cu. mm. up and down. The only uninvolved kidney tissue is at either pole, a little more toward the lower than the upper pole. The pus pockets occur in clusters and are fairly well demarcated from the surrounding kidney parenchyma; they impinge on the top of the pelvis but in no place do they perforate it, and whatever pus there is in the pelvis has entered through the papillae of the calyces. The cortex is 1.5 cm. wide where it is not enroached upon by the pus pockets and is bright reddish-brown. It is sharply differentiated from the pyramids which are more red. In the cortex small pinpoint-sized glomeruli appear as glistening points. The lining of the pelvis is
-
CARBUNCLE OF THE KIDNEY
145
thickened, smooth and pale gray as is also that of the ureter in the lumen in which there are small masses of free pus. The capsule of the kidney is 2 mm. thick and very dense." SYMPTOMS
The symptoms may be very conveniently divided into three groups: General, local, and urinary. General
As a rule these patients are severely ill when they come under the surgeon's care, having been ill for a long period of time. Often no diagnosis has been made. The symptoms are those found in any severe, infectious process of an acute or a chronic nature. Chill. There may or may not be a history of a chill or of chilly sensation. The attack may have been so slight that it is forgotten by the patient or it may have occurred so many weeks before that no recollection remains. Fever. This is always present and is generally very high. In the cases reported in this paper, temperatures of 101.6°, 102.8°, 103° and 103.2°F. were recorded. Loss of appetite, malaise, etc. These symptoms which are common to infection are present. Leucocytosis. This is always present. The highest count in the cases reported here was 22,700 leucocytes. In Eisendrath's case a leucocytosis of 27,000 was found. Local
Pain in the region of the kidney involved though practically constant, varies in its severity. The pain may be described as cramp-like or cutting. In case 1 the pain radiated from the kidney region into the abdomen. Localized tenderness. This was present in both cases, making palpation difficult because of the rigidity of the abdominal and lumbar muscles, although in case 2 the remaining kidney was quite easily palpated because of the absence of local tenderness or rigidity. In several instances the side involved was full and prominent.
-----,
146
HERMAN L. KRETSCHM"ER
Urinary The urinalysis may be practically normal or nearly so. The fact is striking that there is a marked disparity between the illness of the patient and the rather insignificant urinary findings. This can easily be explained from the pathology. Since the lesion is at first confined to the parenchyma of the kidney and there is no communication with the pelvis, the changes in the urine are very slight. In case 2 before his first operation, some pus and staphylococci were found in the urine. These promptly disappeared after the nephrectomy and the urine remained sterile and free from pus for weeks, in spite of the fact that the patient was running a very high fever. In case 1 one specimen showed 25 leucocytes, a second 50 leucocytes, and a third specimen 600 leucocytes per cubic millimeter. These urinary findings agree with those of Barth, Zinn, etc. In two of Barth's cases the urine was perfectly normal for eight days after operation when pus appeared in the urine. Zinn states that the urine in one of his cases was normal. In some cases a small amount of pus was present. Judging from the case reports the urine contained a number of pus cells (Eisendrath) ; a number of leucocytes and erythrocytes (Barth) ; some pus in the urine from the right and left sides (Furniss) a few p\J.S cells (Fischer); a few pus cells (Mc Williams). These foregoing few citations should suffice to show that the urinary findings are insignificant, especially so in cases of the type in which the patient is severely ill. DIAGNOSIS
The diagnosis in both cases was made before operation, and to this end a careful consideration of the history is of the utmost importance. The most significant single fact which gives the clue to the diagnosis is the statement from the patient that recently he had a boil, carbuncle or felon. This statement enlightens the physician as to the probability of an infection of the staphylococcus type acting as a focus from which infecting organisms may be transported via the blood stream to the kidneys.
CARBUNCLE OF THE KIDNEY
147
This statement coupled with the fact that the patient has been severely ill, with a high septic temperature, a persistent leucocytosis with an enlarged tender kidney and urinary findings which are negative or practically negative has lead us to establish the diagnosis. The differentiation between carbuncle and the acute embolic kidney, in which the kidney is studded with small miliary abscesses, may at times be impossible; hence, the diagnosis of an acute suppurative process of the kidney is often made. Likewise, it is impossible to differentiate between a carbuncle of the kidney and a large solitary abscess, which, I believe, may in some instances be the· end-result of a carbuncle. In the cases of small multiple abscesses of the kidney there does not seem to be the same degree of resistance and fixation upon palpation that is present in renal carbuncle. TREATMENT
In carbuncle of the kidney nephrectomy is the operation of election unless the carbuncle is small and the case is seen early, in which event resection might be tried. N ephrectomy was performed in these 2 cases, since the pathological process was so extensive that nothing short of nephrectomy seemed wise. N ephrectomy was also carried out by Israel, Barth, McWilliams and Zinn. In reported cases associated with a perinephritic abscess the true pathology probably was not at first recognized, and the abscess was incised. This failed to relieve the symptoms, a secondary nephrectomy being necessary. Cases of this type have been reported by Barth (two cases), also by Furniss, Fischer and Eisendrath. In cases in which the carbuncle has broken down and gone on to abscess formation and in which a single abscess is present, drainage can easily be instituted.
148
HERMAN L. KRETSCHMER
REFERENCES BARTH: Arch. f. Klin. Chir., 1920, cxiv, 476. E1sENDRATH, D. N.: Surg. Clin., 1920, iv. FISCHER, H.: Ann. Surg., 1917, lxvi, 247. FURNISS, H. D.: N. Y. Med. Jour., 1915, cl, 1917. ISRAEL: Deutsch. med. Wschschr., 1905, xxxi, 1660. McWILLIAMS, C. A.: Med. Rec., 1917, xcii, 215. PHEMISTER: Jour. Amer. Med. Assoc., February 18, 1922, 480. SCHNITZLER, J.: Wien. med. Wschschr., 1913, lxiii, 2551. SouPER, H. R.: Brit. M. J., 1920, i, 288. ZINN, W.: Therap. d. Gegenw., 1912, xiv, 145.
By carbuncle of the kidney is meant an infection of the kidney by staphylococci, secondary to an infection elsewhere by this organism, such as a carbuncle or felon, in which the lesion of the kidney has the gross appearance of a carbuncle as seen in other parts of the body. Although the term "carbuncle of the kidney" is not in general use, there is no doubt in my mind about its clinical entity. This term is not a new one but it is used very infrequently in describing this lesion, Barth, Eisendrath and Isreal having used this term in their writings on this subject. Carbuncle of the kidney should be differentiated from the acute septic or embolic kidney in which the entire organ is studded with small miliary abscesses, as well as from renal abscesses, either solitary or multiple. It is my opinion that a lesion may start as a carbuncle and the entire area involved undergo suppuration, resulting in the production of large abscesses, single or multiple. If an operation is done early, a picture of typical carbuncle is seen: but when operated upon late in the course of the disease, the picture of abscess, either single or multiple, is encountered. There can be no doubt that one form may merge into the other. This was clearly illustrated in case 2 reported in this paper, when at operation the lesions were typical of carbuncle, but months later, at autopsy, were those of abscess formation in the remaining kidney. Carbuncle of the kidney is a metastatic lesion being similar in its origin to the acute septic kidney and perinephritic abscess; which means that there is or was present a lesion elsewhere in the 1 Read at the annual meeting of the American Urological Association, Atlantic City, April 26 to 28, 1922.
137 THE JOURNAL OF UROLOGY, VOL. VIII, NO. 2
138
HERMAN L. KRETSCHMER
body from which point organisms were transplanted to the kidney via the blood-stream. Often this lesion is obvious; at times, however, it is not. The _patient fails, in a number of instances, to tell us of previous attacks of boils, for the reason that he does not think "they amounted to very much" or because he is well of them and has completely forgotten about them. Again, the lesion of the skin may have been so slight that it healed without the patient being aware of its existence, such as lesions between the toes, eczema, etc. Occasionally, even when a carbuncle has occurred, the attending physician may overlook the relationship between the carbuncle and the kidney lesion- to my mind a most significant fact. The predisposing lesions in the two cases ·reported in this paper, were an osteomyelitis of the last phalanx of the right thumb in one case and a carbuncle of the neck in the other case. Phemister has recently called attention to the importance of lesions of the skin in the production of acute osteomyelitis, emphasizing the fact that the skin as a focus is so often overlooked, often forgotten and just as often neglected. Having recently had two cases of carbuncle of the kidney under observation, one unilateral and the other bilateral, in which the primary foci were demonstrable, and since the literature of this country is not characterized by reports of numerous cases of this type, the following two cases may not be without interest. Case 1. Mrs. H., aged thirty-five. Referred by Dr. T . E. Roberts. Admitted to the Presbyterian Hospital, October 25, 1920. In March, 1920, seven months before coming under observation, the patient developed a felon of the right thumb which was incised. One month later a piece of necrotic bone was removed, and on April 27, while the thumb was still suppurating, she gave birthtoachild. About June 7 she experienced an acute pain in the left side, which remained localized. A physician made a diagnosis of prolapsed kidney and she was instructed to wear a pad. The pain was not associated with urination, was dull in character and constant since its onset. Abdominal colic was so intense that she was compelled to double up to get relief. Nausea about half an hour after eating. Frequency of urination; voided about five times during the day and once at night. Urine very brown in color.
CARBUNCLE OF THE KIDNEY
139
Physical examination. Head, neck, heart and lungs, negative. The left half of the abdomen, very prominent and full. In the upper left quadrant a large, hard, irregular mass was palpable, slightly movable upon respiration, and very tender on pressure. Pressure over the back produced a sharp pain, extending into the groin. The mass was compatible with an enlarged, tender kdiney. Both upper and lower poles were palpable. There was an old healed felon of the right thumb. Blood examination. 14,400 leucocytes and hemoglobin 75 per cent. X-ray examination. Negative for stone. Cystoscopy, October 26, 1920. Bladder and lireteral orifices normal. Right ureter catheterized easily and a flow of clear urine obtained. Left ureter easily catheterized but no flow obtained. Urine from the bladder and right ureter negative for pus cells. Cultures showed the right side sterile and colon bacilli in the bladder. Stains for tubercle bacilli were negative. A mixed phenolsulphonephthalein test showed an output of 58 per cent in thirty minutes. Operation, November 4, 1920. The usual oblique lumbar incision was made in the left side and the kidney exposed. The kidney was firmly bound down by thick adhesions and because of these it was difficult to free and deliver the kidney. The tissues around the kidney were somewhat edematous. Ureter was ligated and cut about 1 inch from the pelvis. The pedicle was clamped with two clamps and the kidney removed, then the pedicle was ligated and the clamps removed. Muscles were approximated with heavy gut and cigarette drains were left in place. Patient made an uneventful recovery. Gross description. The kidney was about one-third larger than normal and the anterior surface, in one or two places, irregularly nodular. On section the cortex was 6 mm. thick and retained its markings with the exception of several large abscesses, which contained thick, greenishyellow pus, situated mostly in the anterior half. In close proximity to the larger abscesses were seen several smaller areas that had the appearance of typical carbuncles. When these areas were pressed, thick, greenishyellow pus came to the surface. The posterior surface was smooth and the fibrous capsule very much thickened. The pelvis of the kidney was negative. Cultures of the pus from the abscesses showed hemolytic staphylococci. At the time the patient came under observation the felon had completely healed; hence it was not possible to obtain cultures to determine
·I 140
HERMAN L. KRETSCHMER
whether or not the organisms found in the kidney were identical with the organisms which produced the felon. Case 2. T. C. male, aged thirty-four. Referred by Dr. Weigan and Dr. Benson and admitted to the Presbyterian Hospital, September 15, 1921. During the first week in June, 1921, patient had a carbuncle of the neck which was incised and drained on June 11. When admitted to the hospital the carbuncle had completely healed. August 8, he complained of slight pain in the lower abdomen; perspiration profuse; temperature of 104.6°F. . He was admitted to another hospital where he remained until August 21, and then went home. August 29, his temperature rose suddenly to 102°F.; severenauseaand vomiting. Another attack of fever on September 3, at which time he first noticed that his urine was bloody. The hematuria lasted for three days and was associated with painful urination. Frequency of urination was also present; voided every one and one-half hours during the day and every two hours at night. Patient came under my observation on September 15. Physcial examination. Negative with the exception of the right kidney which was slightly enlarged and tender both in front and behind; some rigidity of the lumbar muscles. X-ray examination. Negative for stone. Blood chemistry. Sugar, 142.00 mgm., urea, 27.00 mgm., uric acid, 4.40 mgm., creatinin, 1.70 mgm., non protein nitrogen 43.00 mgm. Cystoscopy, September 20, 1921. Bladder and urteral orifices normal, and ureters were easily catheterized. Cell counts and cultures were as follows: CELLS (LEUCOCYTES)
Bladder .. . ... .. .... ..... . .. . . ..... . . Right kidney ......... . ..... .. . . .. . . . Left kidney .... ...... ... . .... . ..... .
10
130
60
CULTURES
Staphylococcus albus Sterile Sterile
Functional test. An output of 26 per cent from the right side and 20 per cent from the left side in thirty minutes. Blood examination, September 22, 1921. 16,800 leucocytes. Two Widal tests, negative. Cystoscopy, October 6, 1921. Bladder and ureteral orifices negative. From the left catheter a flow of golden yellow urine was obtained; from
141
CARBUNCLE OF THE KIDNEY
the right side, a very rapid flow of very pale urine, containing a large amount of pus shreds. Pyelogram. Twenty cubic centimeters of sodium bromide was injected into the right catheter. Pyelogram showed traces of the solution apparently extending from the twelfth dorsal to the second lumbar vertebra. Moderate dilatation of the right ureter with some deformity of the pelvis. Cell counts and cultures made at this time were as follows: CELLS
(LEUCOCYTES)
Bladder .... . . .. . ... . . . .. .. . . . . . .... . Right kidney . . . .. . .... . . .. .. . . . .. . . . Left kidney .... ... ... . . ... . .. .. .... .
110 1050
230
CULTURES
Staphylococcus aureus Staphylococcus aureus Sterile
Operation, October 11, 1921. The usual oblique lumbar incision was made over therightside; muscles and perirenalstructures very edematous ; fibrous capsule very thick and slightly edematous and much evidence of perinephritis; inflammatory thickening of the kidney pedicle. A large carbuncle, located nearly at the middle of the surface of the kidney, was noted. Two large clamps were placed on the pedicle, ligation with heavy catgut followed and the kidney was removed. At the end of forty-eight hours the clamps were removed. Gross description. The specimen is a large right kidney weighing 200 grams. It measures 13 by 6 by 4.5 cu. mm. The surfaces are smooth, glistening, and very dark red. Near the center of the posterior surface is a mass, somewhat nearer the upper than the lower pole. It is 4 by 3.5 cu. mm. and protrudes 0.5 cu. mm. from the surface. In this mass near the margin are six small swellings, red at the base with a white cap, each from 2 to 5 mm. in diameter. The cut surface of the kidney shows the cortex fairly pale, and in the medulla, at the center of the kidney, are many small, white opaque areas, irregular in form and irregularly distributed. They are all contained in an area 4 by 3 cu. mm. which corresponds to the swellings on the posterior surface. This shows many small isolated abscesses which upon cut surface has the gross appearance of a carbuncle seen, for example, on the back of the neck. Sectioning shows normal renal tissue, in certain parts of which are sharply demarcated regions, staining a faint blue and characterized chiefly by poorly staining fragmented nuclei and cytoplasm, the latter being quite granular and without cellular walls. A few polymorpho~
142
HERMAN L. KRETSCHMER
nuclear leucocytes are found in and around glomerular tufts and in the interspaces between the tubules. These tubules are filled with a bluestaining homogeneous material and the blood-vessels are engorged with red blood ·cells. A section from another portion of the kidney contains many polymorphonuclears distributed fairly uniformly throughout the entire section, some of them being in the lumen of the tubules among fragmented red blood cells. These tubules have rough epithelial walls due perhaps to partially desquamated eipthelium. Pus from the abscess showed cultures of pure staphylococcus aureus. Post-operative course. A moderate amount of shock followed the operation for which the patient was given rectal drip containing soda bicarbonate and 5 per cent glucose. Two ampules of digifolin were given by intramuscular injection. The drains were removed on the fourth day and small iodoform wicks placed in the wound. At the end of three weeks there was no discharge but the wound was kept open because the temperature persisted. Immediately after the operation the patient's temperature subsided so that it was normal in the morning and only 99.2°F. in the evening. This continued for about ten days when he again had a rise in temperature, going as high as 103°F. The temperature curve was very irregular. The amount of drainage from the wound being very scant and since there were no other findings to explain the temperature, the possibility of some deep-seated infection in the wound was discussed. The wound was reopened but no pus was found . The second operation did not influence the course of the temperature in any way and continued to vary from 98.8° to 102.4°F. We were particularly concerned with the cause of this continued high temperature and on November 17, Dr. Herrick was called in consultation. His findings follow: "Patient is pale. Heart enlarged to the left; a loud systolic murmur present, evidently of organic origin. Chest negative except for a few scattered rales at the right base, and anteriorly the hepatic dullness is 2 inches higher than normal. Abdominal examination, negative. No enlargement of the spleen. One or two doubtful petechial spots over the right arm and chest. " Examination by Dr. Herrick on November 26 showed patient less ill than at previous examination. The heart was the same as before. Another examination on December 15 showed heart and lung condition negative. The spleen was plainly palpable and there was a question whether or not the kidney was palpable.
143
CARBUNCLE OF THE KIDNEY
As the fever continued and as the patient had an organic heart murmur, the possibility of malignant endocarditis was considered and blood
cultures were made. During the course of three weeks, five sets of blood cultures were made, all of which were negative. The possibility of subphrenic abscess was also considered, but this was excluded by physical signs and roentgenograms. Since the temperature and leucocytosis could not be explained on the basis of infection elsewhere in the body, and taking into consideration the fact that the right kidney was removed for a carbuncle, the possibility of infection of the same type in the remaining kdiney was considered and strongly suspected. The various blood cultures, Widal tests and examinations for malaria were carried out, not so much with the object of finding some remote cause for the temperature as it was to exclude these causes. During the entire period of observation the urinary findings are of interest. Needless to state many urinalyses were made. After his nephrectomy all the urine voided was practically clear to the naked eye. Some of the reports showed a few leucocytes. Leucocytes per cu. mm .
November November December December December December December
29, 30, 5, 8, 11, 13, 14,
1921. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1921 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 1921 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 1921 .............. . ................. ... .. . ..... . .. Few 1921..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 1921 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1921 .... ....... ... ...... .. .. .. .. ... .. .. . . . ... ..... 110
An interesting point is the fact that though the patient was seriously ill, was running a high temperature and had a high leucocytosis, yet his urine was perfectly clear and the cell count showed only 30 to 110 pus cells per cu. mm. In one culture a few colonies of staphylococci were found. These were so few and the other cultures made before and after that particular culture being negative, a contamination was considered. The patient left the hospital on December 19, seemingly much improved. At the time of his dischargge the entire situation was again discussed and it was agreed that the cause of his high temperature and high leucocyte count was due to an infection in his remaining kidney and that in all probability it was of the same type as that found at operation in his opposite kidney, namely, carbuncle. The patient was readmitted to the hospital on January 20, 1922, with a small discharging sinus in his wound. After being at home for two
144
HERMAN L. KRETSCHMER
weeks he developed a superficial abscess of his nephrectomy wound from which about 3 ounces of pus were evacuated by Dr. Weigan. During the time he was at home he had an afternoon temperature varying from 101 ° to 103°F., and once he passed very bloody urine. Prior to the attack of hematuria his urine was clear. Immediately afterward large amounts of pus were found in every specimen examined. Apparently the carbuncle or abscess ruptured into the kidney pelvis since pus was constantly found after the hematuria. At the time of admission to the hospital patient's condition wss very critical. The left kidney was enlarged to about twice the size of a normal kidney. On January 28, his blood chemistry was as follows: Urea, 148.0 mgm., uric acid, 13.7 mgm., creatinin, 4.1 mgm., non-protein nitrogen 102.0 mgm. The patient gradually lost strength and died February 9, 1922. The autopsy was performed by Dr. Oberhelmen, pathologist to Presbyterian Hospital, and his report is as follows : "There is a large bulging mass in the left kidney region, larger than the open hand can cover, so that a part of each pole remains exposed. The spleen is huge and bound to the diaphragm behind by strands of fibrous adhesions. That part of the descending colon corresponding to the level of the left kidney is adherent to it by fibrous and fibrinous adhesions for 6 to 8 cm. up and down, and 1 to 2 cm. side to side. One small accidental cut is made into the kidney capsule and from this yellowish-green purulent fluid flows. "The left kidney is asymmetrical, the bulging being more in front than posteriorly. When cut into, thick, purulent, greenish-yellow pus escapes in a large amount. This pus is contained in small pockets, 3 to 10 mm. in diameter. These are surrounded by a grayish-yellow membrane 0.5 mm. thick. The broad surface made by sectioning these pus pockets, has a honeycomb appearance. These pus pockets involve all the kidney tissue for 8 cu. mm. up and down. The only uninvolved kidney tissue is at either pole, a little more toward the lower than the upper pole. The pus pockets occur in clusters and are fairly well demarcated from the surrounding kidney parenchyma; they impinge on the top of the pelvis but in no place do they perforate it, and whatever pus there is in the pelvis has entered through the papillae of the calyces. The cortex is 1.5 cm. wide where it is not enroached upon by the pus pockets and is bright reddish-brown. It is sharply differentiated from the pyramids which are more red. In the cortex small pinpoint-sized glomeruli appear as glistening points. The lining of the pelvis is
-
CARBUNCLE OF THE KIDNEY
145
thickened, smooth and pale gray as is also that of the ureter in the lumen in which there are small masses of free pus. The capsule of the kidney is 2 mm. thick and very dense." SYMPTOMS
The symptoms may be very conveniently divided into three groups: General, local, and urinary. General
As a rule these patients are severely ill when they come under the surgeon's care, having been ill for a long period of time. Often no diagnosis has been made. The symptoms are those found in any severe, infectious process of an acute or a chronic nature. Chill. There may or may not be a history of a chill or of chilly sensation. The attack may have been so slight that it is forgotten by the patient or it may have occurred so many weeks before that no recollection remains. Fever. This is always present and is generally very high. In the cases reported in this paper, temperatures of 101.6°, 102.8°, 103° and 103.2°F. were recorded. Loss of appetite, malaise, etc. These symptoms which are common to infection are present. Leucocytosis. This is always present. The highest count in the cases reported here was 22,700 leucocytes. In Eisendrath's case a leucocytosis of 27,000 was found. Local
Pain in the region of the kidney involved though practically constant, varies in its severity. The pain may be described as cramp-like or cutting. In case 1 the pain radiated from the kidney region into the abdomen. Localized tenderness. This was present in both cases, making palpation difficult because of the rigidity of the abdominal and lumbar muscles, although in case 2 the remaining kidney was quite easily palpated because of the absence of local tenderness or rigidity. In several instances the side involved was full and prominent.
-----,
146
HERMAN L. KRETSCHM"ER
Urinary The urinalysis may be practically normal or nearly so. The fact is striking that there is a marked disparity between the illness of the patient and the rather insignificant urinary findings. This can easily be explained from the pathology. Since the lesion is at first confined to the parenchyma of the kidney and there is no communication with the pelvis, the changes in the urine are very slight. In case 2 before his first operation, some pus and staphylococci were found in the urine. These promptly disappeared after the nephrectomy and the urine remained sterile and free from pus for weeks, in spite of the fact that the patient was running a very high fever. In case 1 one specimen showed 25 leucocytes, a second 50 leucocytes, and a third specimen 600 leucocytes per cubic millimeter. These urinary findings agree with those of Barth, Zinn, etc. In two of Barth's cases the urine was perfectly normal for eight days after operation when pus appeared in the urine. Zinn states that the urine in one of his cases was normal. In some cases a small amount of pus was present. Judging from the case reports the urine contained a number of pus cells (Eisendrath) ; a number of leucocytes and erythrocytes (Barth) ; some pus in the urine from the right and left sides (Furniss) a few p\J.S cells (Fischer); a few pus cells (Mc Williams). These foregoing few citations should suffice to show that the urinary findings are insignificant, especially so in cases of the type in which the patient is severely ill. DIAGNOSIS
The diagnosis in both cases was made before operation, and to this end a careful consideration of the history is of the utmost importance. The most significant single fact which gives the clue to the diagnosis is the statement from the patient that recently he had a boil, carbuncle or felon. This statement enlightens the physician as to the probability of an infection of the staphylococcus type acting as a focus from which infecting organisms may be transported via the blood stream to the kidneys.
CARBUNCLE OF THE KIDNEY
147
This statement coupled with the fact that the patient has been severely ill, with a high septic temperature, a persistent leucocytosis with an enlarged tender kidney and urinary findings which are negative or practically negative has lead us to establish the diagnosis. The differentiation between carbuncle and the acute embolic kidney, in which the kidney is studded with small miliary abscesses, may at times be impossible; hence, the diagnosis of an acute suppurative process of the kidney is often made. Likewise, it is impossible to differentiate between a carbuncle of the kidney and a large solitary abscess, which, I believe, may in some instances be the· end-result of a carbuncle. In the cases of small multiple abscesses of the kidney there does not seem to be the same degree of resistance and fixation upon palpation that is present in renal carbuncle. TREATMENT
In carbuncle of the kidney nephrectomy is the operation of election unless the carbuncle is small and the case is seen early, in which event resection might be tried. N ephrectomy was performed in these 2 cases, since the pathological process was so extensive that nothing short of nephrectomy seemed wise. N ephrectomy was also carried out by Israel, Barth, McWilliams and Zinn. In reported cases associated with a perinephritic abscess the true pathology probably was not at first recognized, and the abscess was incised. This failed to relieve the symptoms, a secondary nephrectomy being necessary. Cases of this type have been reported by Barth (two cases), also by Furniss, Fischer and Eisendrath. In cases in which the carbuncle has broken down and gone on to abscess formation and in which a single abscess is present, drainage can easily be instituted.
148
HERMAN L. KRETSCHMER
REFERENCES BARTH: Arch. f. Klin. Chir., 1920, cxiv, 476. E1sENDRATH, D. N.: Surg. Clin., 1920, iv. FISCHER, H.: Ann. Surg., 1917, lxvi, 247. FURNISS, H. D.: N. Y. Med. Jour., 1915, cl, 1917. ISRAEL: Deutsch. med. Wschschr., 1905, xxxi, 1660. McWILLIAMS, C. A.: Med. Rec., 1917, xcii, 215. PHEMISTER: Jour. Amer. Med. Assoc., February 18, 1922, 480. SCHNITZLER, J.: Wien. med. Wschschr., 1913, lxiii, 2551. SouPER, H. R.: Brit. M. J., 1920, i, 288. ZINN, W.: Therap. d. Gegenw., 1912, xiv, 145.