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Computed tomography of acute renal abscess due to salmonella chester
Compurerixd /+I&/. Vol. IO, No. I, pp. 41-44. Printed in the U.S.A. All rights reserved
1986
Copyright
I(
0730-4X62/X6 $3.00 + 0.00 1986 Pergamon Press Ltd
COMPUTED TOMOGRAPHY OF ACUTE RENAL ABSCESS DUE TO SALMONELLA CHESTER GEORGE
0.
BORRERO,‘* S. ZAFAR H. JAFRI,’ PAUL M. VAZQUEZ,’
MELVIN L. HOLLOWELL’ and GEORGE A. KLINC’ Departments of ‘Radiology and ‘Urology. Detroit Receiving Hospital (G.O.B.), Detroit. MI 48201 and Hutzel Hospital (S.Z.H.J., P.M.V., M.L.H.), Harper-Grace Hospitals (G.A.K.), Wayne State University. Detroit, (Received
MI 48202.
31 July 1985: recriwd,for
U.S.A.
publication
8 Nowmher 1985)
Abstract-A case of renal abscess caused by an unusual Salmonella serotype is presented in which the clinical presentation was suggestive of renal neoplasia. The CT findings of renal abscesses and neoplasm are discussed as well as a brief discussion on the epidemiology of Salmonella infections. Salmonella
Computed
tomography
Abscess
INTRODUCTION
Focal Salmonella species infections, as opposed to gastroenteritis and enteric fever, are an uncommon manifestation of salmonellosis occurring in fewer than 8% of cases, with focal involvement of the genito--urinary tract occurring in less than 1% [I]. Considering all hospitalizations for Salmonella species disease, the incidence of suppurative abscess formation has been reported to range from 0 to I .7% in several published series [2Z6]. We report a case of renal abscess due to an unusual serotype of Salmonella which, clinically, presented as a renal neoplasm.
CASE
REPORT
A 72-year-old white male was admitted to the hospital with a 2-week history of fever, chills, right flank pain and passage of dark red blood in the urine. Pertinent past medical history included intermittent bouts of diarrhea which were treated symptomatically with home remedies. Social history was significant in that the patient had worked as a butcher for most of his adult life. Physical exam revealed a well-developed, elderly male in moderate distress due to the right flank pain with an oral temperature of 37.7’C. Abdominal exam demonstrated a large, tender mass palpable in the right upper quadrant. Urinalysis revealed grossly bloody urine with many RBCs and WBCs and few bacteria per high powered field. Initial chest radiograph showed zones of platelike atalectasis at the right lung base and a small right pleural effusion. An intravenous urogram revealed poor definition of the right renal outline and a large mass arising from the upper pole of the right kidney. Lower pole calices were compressed by the mass and were mildly hydronephrotic. Ultrasound exam showed the mass to be hypoechoic with scattered bright echoes within the mass, and in retrospect, these represented small collections of gas (Fig. 1). Gallstones were incidentally demonstrated. Computed tomographic evaluation of the abdomen showed the right kidney with a large, thick walled, relatively hypodense, upper pole mass. There was enhancement of the mass wall and central attenuation coefficients ranged from 19 to 33 H.U. (Fig. 2). Small pockets of gas were present within the mass. There was no demonstrable involvement of adjacent viscera, lymph nodes or of vascular structures on CT examination. In view of the patient’s gross hematuria and with the sonographic findings of a solid mass, the preoperative impression was that of a large necrotic neoplasm. Cystoscopy and retrograde pyelography showed splaying of upper pole calices by the right renal mass, however, no significant bladder or ureteral pathology was identified. A laparotomy was * Please address reprint requests and correspondence to: George Receiving Hospital. 4201 So. Antoine. Detroit, MI 48201. U.S.A. 41
0.
Borrero,
M.D..
Department
of Radiology.
Detroit
42
GEOWF 0. B~KKEIKI c/ (I/.
-
--Fig. 1. Sagittal sonogram pole. Echogenic
Fig. 2. Computed
-
of the right kidney (k) with a large hypoechoic mass (m) originating from its upper foci seen within the mass (arrows) suggest the presence of gas. L = liver
tomogram through the upper abdomen wall is present as well as small pockets
demonstrating of gas within
a large right renal mass (m). A thick the mass (arrows).
CT of acute
43
renal abscess
performed and revealed a large, firm renal mass originating from the upper pole of the right kidney. A right radical nephrectomy and a cholecystectomy were performed. Pathologic examination showed an enlarged kidney measuring 16 x I2 x 10 cm and weighing 1030 g. The upper pole mass measured 13 x 11 x 11 cm and on sectioning, yielded 250 cc of purulent, yellow-green fluid. Microscopically, the mass wall was composed of heavy fibrous tissue with evidence of acute and chronic inflammation and atrophic renal parenchyma on its outer surface. Culture of the fluid yielded Salmonella Chester. Cultures of the gallbladder and its contents as well as several urine cultures obtained pre-operatively, yielded identical results. The patient’s postoperative course was uneventful. He was placed on oral TrimethoprimSulfamethoxazole 16&800 mg b.i.d. which was continued for a total of 6 weeks. Follow-up urine His family was tested with urine and stool cultures upon and stool cultures were negative. recommendations
of the Public
Health
Department
and these were found
to be negative.
DISCUSSION The genus Salmonella consists of three species and includes more than 1700 different serotypes. In contrast to classic Salmonella typhii infection, where the human carrier is the sole source of the infecting organism, contaminated animals and animal products represent the major source of other Salmonella infections. Poultry and beef products represent the largest sources of nontyphoid Salmonella infection in the U.S. [7]. Although gastroenteritis is the most common presentation in infected individuals, focal manifestations occasionally occur with an incidence of approx 8%. Focal involvement of the genitourinary tract is a rare manifestation occurring in less than 1% of cases [l]. Our case is interesting in that Salmonella Chester has been implicated rarely as a cause of human infection, with two cases reported by MacCready et a/. [4] and a case of splenic abscess reported by Scott et al. [8]. There are no previous reports of renal abscess caused by this serotype. It is presumed that our patient was a chonic carrier of Salmonella Chester as evidenced by positive cultures obtained from the urine, gallbladder and bile. It should be noted, however. that stool cultures obtained prior to surgery were negative for Salmonella species. In all likelihood, the patient’s repeated occupational exposure to animals and animal products predisposed him to infection by this unusual serotype of Salmonella. The characteristics of intra-abdominal abscesses and of renal neoplasia using CT have been detailed in the radiologic literature [9, IO]. Although CT is reliable in determining the presence of renal malignancy, there are no universally accepted diagnostic criteria. In general, the following characteristics are suggestive of cancer [9]. Attenuation coefficient close to that of renal parenchyma and, often. heterogeneous. Definite contrast enhancement. usually less than normal parenchyma. An ill-defined interface with surrounding parenchyma. Secondary findings such as enlargement of regional lymph nodes. nodular areas of soft tissue attenuation within the perinephric space. or gross invasion of the inferior vena cava or main renal vein. Rarely, a necrotic but noninfected tumor may contain pockets of gas [l I]. In a series of 29 patients reported by Callen, the characteristics of abscesses were described [IO] and these included a definable wall or rim (38%), the presence of central low density areas which ranged from -8 to +36 H.U. (68), with the majority being less than f20 H.U.. the presence of extraluminal gas (38%). A fluid collection which contains gas is the only specific finding for an abscess. Callen has concluded that with a clinical setting of abdominal pain, fever. local tenderness or palpable mass, any mass seen on CT scan should be considered an abscess despite its CT numbers. The findings in a renal abscess are nonspecific and, in general. are similar to abscesses in extra-renal locations [I?].
CONCLUSIONS CT evaluation of our patient was helpful in demonstrating the presence of gas pockets within the renal mass. Delineation of adjacent viscera and vascular structures showed these to be free of involvement. This limited the surgical procedure to the area of interest and diminished the attendant risks of prolonged exploration or of disseminating infection. In patients who are poor surgical
GEORGE 0.
44
B~RRER~ ci al.
candidates and have an established diagnosis of abscess, CT has proven to be helpful in the placement of percutaneous indwelling drainage catheters [13] and in assessing adequacy of drainage or of antibiotic therapy. The finding of gas pockets within the mass in our patient should have alerted us to the fact that, in all probability, it represented an abscess even though this is not a pathognomonic finding. The patient’s gross hematuria combined with ultrasonographic criteria for a solid mass misled us to the conclusion that this was a necrotic neoplasm. AcknoM,ledgenzenr-The
authors
wish to thank
MS Betty lsmail
for her assistance
in the preparation
of this manuscript.
REFERENCES I I. Saphra and J. W. Winter, Clinical manifestations of Salmonellosis in man, N. Engl. J. Med. 256, 112881134 (1957). 2. F. Seligman, Salmonella infections in the USA, J. Immunol. 54, 69-85 (1946). 3. C. Cherubin, A. C. New, P. Imperato. R. P. Harvey and N. Bellen, Septicemia with nontyphoid Salmonella, ,+fedicinc 53, 3655376 (1975). 4. R. A. MacCready, J. P. Reardon and 1. Saphra, Salmonellosis in Massachusetts, N. _!+zg. J. Med. 256, 1121- II28 (1957). 5. G. M. Eisenberg, L. Brodsky, W. Weiss and H. F. Flippin, Clinical and microbiological aspects of Salmonellosis. A~I. J. Med. Sci. 235, 497-508 (1958). 6. C. Cherubin, T. Fodor, L. I. Denmark, C. S. Master. H. T. Fuerst and J. W. Winter, Symptoms, septicemia and death in Salmonellosis, Anr. J. Epidem. 90, 285-291 (1969). I. W. K. Joklet, H. P. Willet and D. B. Mos. Zinsser Microbiolog_v, pp. 616-618. AppletonCentury~Crofts, Norwalk, Corm. (1984). 8. H. K. Scott, H. W. Thomas and R. 0. Walters, Acute splenic abscess due to Salmonella Chester. Br. Med. J. 6062, 688 (1977). 9. D. M. Balfe. B. L. McClennan, R. J. Stanley, P. J. Weyman and S. S. Salgel, Evaluation of renal masses considered indeterminate on computed tomography, Radiology 142, 421428 (1982). 10. P. W. Callen, Computed tomographic evaluation of abdominal and pelvic abscesses, Radiology 131, 171-175 (1979). 11. A. A. Moss, G. Gamsu and H. K. Genant, Computed Tomogr&v qf the Bo~I,, p. 970. Saunders, Philadelphia. Pa (1983). in the diagnosis of renal and perirenal 12. G. Mendez Jr, M. B. Isikoff and G. Morrillo. The role of computed tomography abscesses, J. Ural. 122, 582-586 (1979). New interventional techniques in the diagnosis and 13. J. R. Haaga. C. George, A. J. Weinstein and A. M. Cooperman. Radio1 clin. N. Am. 17, 485. 513 (1979). management of inflammatory disease within the abdomen, About the Author-GEORGE 0. BORREKO, M.D. received his Bachelor of Science degree from the University of Miami in December 1975. He obtained his M.D. degree from Cetec University School of Medicine in 1981, He completed one year of training in Internal Medicine in the Wayne State University Affiliated Hospitals, Detroit, Michigan before entering the Diagnostic Radiology residency training program. He is completing this training in Diagnostic Radiology and is serving as Chief Resident for the current year, About the Author-SYEu ZAFAR HASSAN JAFRI. M.D. received his undergraduate and graduate training at Osmania Medical College in Hyderabad. India and was granted his M.D. degree in 1973. He completed a Diagnostic Radiology residency program at the State University of New York at Buffalo. New York in 1979. He completed a fellowship in Diagnostic Radiology at the University of Florida in Gainesville, Florida and a fellowship in Computed Tomography and Ultrasound at William Beaumont Hospital in Royal Oak, Michigan. At present he is a staff radiologist at William Beaumont Hospital. He is the author of a number of scientific publications, many related to CT and Ultrasound. About the Author-PAUL M. VAZQUEZ, D.O. received his D.O. degree from Kirksville College of Osteopathic Medicine in Kirksville, Ohio in 1981. He served an internship and a residency in General Surgery at Botsford General Hospital in Farmington Hills, Michigan from 1981 to 1984. He is currently a resident in Urology at Wayne State University Affiliated Hospitals in Detroit, Michigan. About the Author-MELVIN L. HOLLOWELL. M.D. received his M.D. degree in the early 1960s and completed a residency in Urology at Wayne State University Hospitals, Detroit. Michigan in 1967. He is currently a Clinical Professor of Urology at Wayne State University School of Medicine. About the Author-GEORGE A. KLING, M.D. received his M.D. degree from the University of Michigan and completed an internship and a residency in Radiology at Harper Hospital in Detroit, Michigan. He is Chief of Radiology at Harper-Grace Hospitals and Detroit Receiving Hospital and University Health Center. In addition he is Chairman of the Department of Radiology. Wayne State University and is the Program Director for the Diagnostic Radiology residency training program.
1986
Copyright
I(
0730-4X62/X6 $3.00 + 0.00 1986 Pergamon Press Ltd
COMPUTED TOMOGRAPHY OF ACUTE RENAL ABSCESS DUE TO SALMONELLA CHESTER GEORGE
0.
BORRERO,‘* S. ZAFAR H. JAFRI,’ PAUL M. VAZQUEZ,’
MELVIN L. HOLLOWELL’ and GEORGE A. KLINC’ Departments of ‘Radiology and ‘Urology. Detroit Receiving Hospital (G.O.B.), Detroit. MI 48201 and Hutzel Hospital (S.Z.H.J., P.M.V., M.L.H.), Harper-Grace Hospitals (G.A.K.), Wayne State University. Detroit, (Received
MI 48202.
31 July 1985: recriwd,for
U.S.A.
publication
8 Nowmher 1985)
Abstract-A case of renal abscess caused by an unusual Salmonella serotype is presented in which the clinical presentation was suggestive of renal neoplasia. The CT findings of renal abscesses and neoplasm are discussed as well as a brief discussion on the epidemiology of Salmonella infections. Salmonella
Computed
tomography
Abscess
INTRODUCTION
Focal Salmonella species infections, as opposed to gastroenteritis and enteric fever, are an uncommon manifestation of salmonellosis occurring in fewer than 8% of cases, with focal involvement of the genito--urinary tract occurring in less than 1% [I]. Considering all hospitalizations for Salmonella species disease, the incidence of suppurative abscess formation has been reported to range from 0 to I .7% in several published series [2Z6]. We report a case of renal abscess due to an unusual serotype of Salmonella which, clinically, presented as a renal neoplasm.
CASE
REPORT
A 72-year-old white male was admitted to the hospital with a 2-week history of fever, chills, right flank pain and passage of dark red blood in the urine. Pertinent past medical history included intermittent bouts of diarrhea which were treated symptomatically with home remedies. Social history was significant in that the patient had worked as a butcher for most of his adult life. Physical exam revealed a well-developed, elderly male in moderate distress due to the right flank pain with an oral temperature of 37.7’C. Abdominal exam demonstrated a large, tender mass palpable in the right upper quadrant. Urinalysis revealed grossly bloody urine with many RBCs and WBCs and few bacteria per high powered field. Initial chest radiograph showed zones of platelike atalectasis at the right lung base and a small right pleural effusion. An intravenous urogram revealed poor definition of the right renal outline and a large mass arising from the upper pole of the right kidney. Lower pole calices were compressed by the mass and were mildly hydronephrotic. Ultrasound exam showed the mass to be hypoechoic with scattered bright echoes within the mass, and in retrospect, these represented small collections of gas (Fig. 1). Gallstones were incidentally demonstrated. Computed tomographic evaluation of the abdomen showed the right kidney with a large, thick walled, relatively hypodense, upper pole mass. There was enhancement of the mass wall and central attenuation coefficients ranged from 19 to 33 H.U. (Fig. 2). Small pockets of gas were present within the mass. There was no demonstrable involvement of adjacent viscera, lymph nodes or of vascular structures on CT examination. In view of the patient’s gross hematuria and with the sonographic findings of a solid mass, the preoperative impression was that of a large necrotic neoplasm. Cystoscopy and retrograde pyelography showed splaying of upper pole calices by the right renal mass, however, no significant bladder or ureteral pathology was identified. A laparotomy was * Please address reprint requests and correspondence to: George Receiving Hospital. 4201 So. Antoine. Detroit, MI 48201. U.S.A. 41
0.
Borrero,
M.D..
Department
of Radiology.
Detroit
42
GEOWF 0. B~KKEIKI c/ (I/.
-
--Fig. 1. Sagittal sonogram pole. Echogenic
Fig. 2. Computed
-
of the right kidney (k) with a large hypoechoic mass (m) originating from its upper foci seen within the mass (arrows) suggest the presence of gas. L = liver
tomogram through the upper abdomen wall is present as well as small pockets
demonstrating of gas within
a large right renal mass (m). A thick the mass (arrows).
CT of acute
43
renal abscess
performed and revealed a large, firm renal mass originating from the upper pole of the right kidney. A right radical nephrectomy and a cholecystectomy were performed. Pathologic examination showed an enlarged kidney measuring 16 x I2 x 10 cm and weighing 1030 g. The upper pole mass measured 13 x 11 x 11 cm and on sectioning, yielded 250 cc of purulent, yellow-green fluid. Microscopically, the mass wall was composed of heavy fibrous tissue with evidence of acute and chronic inflammation and atrophic renal parenchyma on its outer surface. Culture of the fluid yielded Salmonella Chester. Cultures of the gallbladder and its contents as well as several urine cultures obtained pre-operatively, yielded identical results. The patient’s postoperative course was uneventful. He was placed on oral TrimethoprimSulfamethoxazole 16&800 mg b.i.d. which was continued for a total of 6 weeks. Follow-up urine His family was tested with urine and stool cultures upon and stool cultures were negative. recommendations
of the Public
Health
Department
and these were found
to be negative.
DISCUSSION The genus Salmonella consists of three species and includes more than 1700 different serotypes. In contrast to classic Salmonella typhii infection, where the human carrier is the sole source of the infecting organism, contaminated animals and animal products represent the major source of other Salmonella infections. Poultry and beef products represent the largest sources of nontyphoid Salmonella infection in the U.S. [7]. Although gastroenteritis is the most common presentation in infected individuals, focal manifestations occasionally occur with an incidence of approx 8%. Focal involvement of the genitourinary tract is a rare manifestation occurring in less than 1% of cases [l]. Our case is interesting in that Salmonella Chester has been implicated rarely as a cause of human infection, with two cases reported by MacCready et a/. [4] and a case of splenic abscess reported by Scott et al. [8]. There are no previous reports of renal abscess caused by this serotype. It is presumed that our patient was a chonic carrier of Salmonella Chester as evidenced by positive cultures obtained from the urine, gallbladder and bile. It should be noted, however. that stool cultures obtained prior to surgery were negative for Salmonella species. In all likelihood, the patient’s repeated occupational exposure to animals and animal products predisposed him to infection by this unusual serotype of Salmonella. The characteristics of intra-abdominal abscesses and of renal neoplasia using CT have been detailed in the radiologic literature [9, IO]. Although CT is reliable in determining the presence of renal malignancy, there are no universally accepted diagnostic criteria. In general, the following characteristics are suggestive of cancer [9]. Attenuation coefficient close to that of renal parenchyma and, often. heterogeneous. Definite contrast enhancement. usually less than normal parenchyma. An ill-defined interface with surrounding parenchyma. Secondary findings such as enlargement of regional lymph nodes. nodular areas of soft tissue attenuation within the perinephric space. or gross invasion of the inferior vena cava or main renal vein. Rarely, a necrotic but noninfected tumor may contain pockets of gas [l I]. In a series of 29 patients reported by Callen, the characteristics of abscesses were described [IO] and these included a definable wall or rim (38%), the presence of central low density areas which ranged from -8 to +36 H.U. (68), with the majority being less than f20 H.U.. the presence of extraluminal gas (38%). A fluid collection which contains gas is the only specific finding for an abscess. Callen has concluded that with a clinical setting of abdominal pain, fever. local tenderness or palpable mass, any mass seen on CT scan should be considered an abscess despite its CT numbers. The findings in a renal abscess are nonspecific and, in general. are similar to abscesses in extra-renal locations [I?].
CONCLUSIONS CT evaluation of our patient was helpful in demonstrating the presence of gas pockets within the renal mass. Delineation of adjacent viscera and vascular structures showed these to be free of involvement. This limited the surgical procedure to the area of interest and diminished the attendant risks of prolonged exploration or of disseminating infection. In patients who are poor surgical
GEORGE 0.
44
B~RRER~ ci al.
candidates and have an established diagnosis of abscess, CT has proven to be helpful in the placement of percutaneous indwelling drainage catheters [13] and in assessing adequacy of drainage or of antibiotic therapy. The finding of gas pockets within the mass in our patient should have alerted us to the fact that, in all probability, it represented an abscess even though this is not a pathognomonic finding. The patient’s gross hematuria combined with ultrasonographic criteria for a solid mass misled us to the conclusion that this was a necrotic neoplasm. AcknoM,ledgenzenr-The
authors
wish to thank
MS Betty lsmail
for her assistance
in the preparation
of this manuscript.
REFERENCES I I. Saphra and J. W. Winter, Clinical manifestations of Salmonellosis in man, N. Engl. J. Med. 256, 112881134 (1957). 2. F. Seligman, Salmonella infections in the USA, J. Immunol. 54, 69-85 (1946). 3. C. Cherubin, A. C. New, P. Imperato. R. P. Harvey and N. Bellen, Septicemia with nontyphoid Salmonella, ,+fedicinc 53, 3655376 (1975). 4. R. A. MacCready, J. P. Reardon and 1. Saphra, Salmonellosis in Massachusetts, N. _!+zg. J. Med. 256, 1121- II28 (1957). 5. G. M. Eisenberg, L. Brodsky, W. Weiss and H. F. Flippin, Clinical and microbiological aspects of Salmonellosis. A~I. J. Med. Sci. 235, 497-508 (1958). 6. C. Cherubin, T. Fodor, L. I. Denmark, C. S. Master. H. T. Fuerst and J. W. Winter, Symptoms, septicemia and death in Salmonellosis, Anr. J. Epidem. 90, 285-291 (1969). I. W. K. Joklet, H. P. Willet and D. B. Mos. Zinsser Microbiolog_v, pp. 616-618. AppletonCentury~Crofts, Norwalk, Corm. (1984). 8. H. K. Scott, H. W. Thomas and R. 0. Walters, Acute splenic abscess due to Salmonella Chester. Br. Med. J. 6062, 688 (1977). 9. D. M. Balfe. B. L. McClennan, R. J. Stanley, P. J. Weyman and S. S. Salgel, Evaluation of renal masses considered indeterminate on computed tomography, Radiology 142, 421428 (1982). 10. P. W. Callen, Computed tomographic evaluation of abdominal and pelvic abscesses, Radiology 131, 171-175 (1979). 11. A. A. Moss, G. Gamsu and H. K. Genant, Computed Tomogr&v qf the Bo~I,, p. 970. Saunders, Philadelphia. Pa (1983). in the diagnosis of renal and perirenal 12. G. Mendez Jr, M. B. Isikoff and G. Morrillo. The role of computed tomography abscesses, J. Ural. 122, 582-586 (1979). New interventional techniques in the diagnosis and 13. J. R. Haaga. C. George, A. J. Weinstein and A. M. Cooperman. Radio1 clin. N. Am. 17, 485. 513 (1979). management of inflammatory disease within the abdomen, About the Author-GEORGE 0. BORREKO, M.D. received his Bachelor of Science degree from the University of Miami in December 1975. He obtained his M.D. degree from Cetec University School of Medicine in 1981, He completed one year of training in Internal Medicine in the Wayne State University Affiliated Hospitals, Detroit, Michigan before entering the Diagnostic Radiology residency training program. He is completing this training in Diagnostic Radiology and is serving as Chief Resident for the current year, About the Author-SYEu ZAFAR HASSAN JAFRI. M.D. received his undergraduate and graduate training at Osmania Medical College in Hyderabad. India and was granted his M.D. degree in 1973. He completed a Diagnostic Radiology residency program at the State University of New York at Buffalo. New York in 1979. He completed a fellowship in Diagnostic Radiology at the University of Florida in Gainesville, Florida and a fellowship in Computed Tomography and Ultrasound at William Beaumont Hospital in Royal Oak, Michigan. At present he is a staff radiologist at William Beaumont Hospital. He is the author of a number of scientific publications, many related to CT and Ultrasound. About the Author-PAUL M. VAZQUEZ, D.O. received his D.O. degree from Kirksville College of Osteopathic Medicine in Kirksville, Ohio in 1981. He served an internship and a residency in General Surgery at Botsford General Hospital in Farmington Hills, Michigan from 1981 to 1984. He is currently a resident in Urology at Wayne State University Affiliated Hospitals in Detroit, Michigan. About the Author-MELVIN L. HOLLOWELL. M.D. received his M.D. degree in the early 1960s and completed a residency in Urology at Wayne State University Hospitals, Detroit. Michigan in 1967. He is currently a Clinical Professor of Urology at Wayne State University School of Medicine. About the Author-GEORGE A. KLING, M.D. received his M.D. degree from the University of Michigan and completed an internship and a residency in Radiology at Harper Hospital in Detroit, Michigan. He is Chief of Radiology at Harper-Grace Hospitals and Detroit Receiving Hospital and University Health Center. In addition he is Chairman of the Department of Radiology. Wayne State University and is the Program Director for the Diagnostic Radiology residency training program.