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Infected Solitary Cyst of the Kidney
TnE .ToURN-\L OF UROLOGY
Vol. 83, No. 1, January 1960 Printed in U.S.A.
INFECTED SOLITARY CYST OF THE KIDNEY STANLEY D. CHOVNICK
AND
DAVID S. SILVERT
From the Departments of Urology, Albert Einstein College of Medicine, Brom; Hospital Center, New York, N. Y. and Danbury Hospital, Danbury, Conn.
Spontaneous infec:tion of solitary cysts of the kidney oceur so infrequently that an adequate description is not readily obtained in standard textbooks. Aside from a recent case report by Nelson and Hooper in 1952, 1 other articles have been relatively rare. H. B. Swecetser2 reported a case in 1929 and gave reference to another case reported by Patel and Mallet-Guy 3 in the same year. Additional cases have been reported as well in the foreign literature by Cassioli in 1917, 4 Bocminghaus in 1935, 5 Botta 11/Iicca in 1930, 6 Fang7 in 1938 and 2 cases by Cibert in 1937. 8 · 9 Llewelyn Davies10 and Daviclson 11 reported cases in 1938 and 1940 respectively with good results after nephrectomy. Chalkley and Sutton12 reported the first and only case in a child bringing the number of cases in the world's literature to twelve. Because of the paucity of reports on this lesion and because of a successful conservative operative approach, the following case is presented.
the right flank and right upper quadrant, which worsened during thP clay, and required hei admission to the hospital by evening. The was clesnibed as being a deep, steady ache with occasional colicky manifestations and loc:11.ecl predominantly in the right upper Fever and chills associated with nausea and vomiting continued throughout the day. Her bowel movements and menstrual periods \1·crr normal. She had no urinary complaints. Pertinent findings in the past history were similar episodes of pain and fover on three previous occasions, in 1951, and 1954 and November 1958. The latter was interprded biliary colic ..-U no time had there been an mologic eYaluation. The patient was confined to sanatorium for 10 months in 1952 and received treatment for pulmonary tuberculosis with streptomycin and PAS. She had been follo1,·ed and found "inactive" on annual examinations since that time. Examination at the time of admission vealed an asthenic, pale, febrile woman obvious discomfort referred to the upper abdc,. men. The abdomen was soft except for mocl(-:rnte guarding, marked tenderness in the right upper quadrant and to a lesser dcigree in the lower quadrant. The left side of the abdomen showed rebound tenderru"ss referred to the right. There was marked right flank and costn. vertebral angle tenderness. Her tempemturc wr~R 102 degrees. The remainder of the examination was not remarkable. Examination of a catheterized urine on admission showed 50--60 white, blood cells and 10-15 red blood cells. Another obtained 24 hours later revealed 3-4 whit;e blood cells with a rare clump and 1--2 reel bloorl cells. The patient's hemoglobin was J 3 gm. pc:r cent, hematocrit 40 per cent, white count with a polymorphonuclcar kukocytosis. Gailbladder ancl gastrointestinal series were essc:ntially negative. The patient was treated with intn.1venmrn foedings, nasogastric suction because of
CASE REPORT
A 27-year-olcl white woman was admitted to the Danbury Hospital on January 23, 1959. She had symptoms of cystitis approximately one week prior to admission and vvas treated by her family physician with alleviation of the symptoms. Early in the morning of the clay of admission, the patient experienced severe colic in Accepted for publication ,June 30, 1959. 1 Nelson, C. B. and Hooper, C. J. Urol., 68: 1952. , H. B.: Minn. 12: 786, 1929. 3 Patel, JV[. and M.: d'nrol., 19: 316, 1925. 4 Cassioli, C.: Revista ospedal, Roma., 7: 151.
J:
1917.
5 Boeminghaus: Ztschr. f. Urol., 29; 191, 1935. "Botta Micca, A.: Riv, san. Siciliana., 18: 1566, 1930. 7 Fang, C. H.: Chin. Med. J 53: 221, 1938. 8 Gibert, J.: J. d'urol., 42: 1937. 9 Ibid. 43: 325, 1987 10 Davies, J. L.: Proc. Roy. Soc. Med., 32: 543, 1938. n Davidson, B.: N. Y. State J. ;VIed., 40: 875, 1940. 12 Chalkley, T. S. iLnd Sutton, L. E., Jr.: J.
Urol., 50: 414, 1943.
7
8
STANLEY D. CHOVNICK AND DAVID S. SILVERT
Fm. 1. Excretory right pyelogram shows incomplete filling of calyceal system with a possible space-occupying lesion in lower pole. and tetracycline therapy. Her temperature ranged daily up to 102 degrees. Although she improved gradually, tenderness and guarding continued mainly in the right upper quadrant. On the sixth hospital day, urologic consultation was obtained. Intravenous pyelograms showed a normally functioning left kidney and incomplete filling of the right calyceal system with a possible space occupying lesion in the lower pole (fig. 1). Cystoscopy demonstrated low grade cystitis with normal appearing ureteral orifices. Urine specimens showed 7-8 white blood cells in the bladder urine and 4-5 red blood cells from the right ureter. Gram positive cocci in pairs and short chains were seen in smears of both bladder and ureteral urine, but no growth resulted in cultures of urine collected both on admission and at the time of cystoscopy. On the basis of the urinary smears, the patient was placed on novobiocin and her temperature coincidentally fell to normal levels. Retrograde pyelograms (fig. 2) showed incomplete filling of the right lower and middle calyces which appeared to be rearranged and distorted. Prior to surgery, an enlarged right kidney could be palpated. Surgery was performed on the tenth hospital day. The perinephric tissues were edematous and the lower pole of the right kidney enlarged two and one-half times. A cystic mass was felt
FrG. 2. Retrograde pyelogram shows rearrangement and distortion of middle and lower calyces with little displacement of transverse colon.
and needle aspiration recovered 75 cc white non-odorous pus. Incision, drainage and excision of the cyst wall were performed and specimens sent for routine and acid fast culture as well as for microscopic pathologic examination. No communication could be demonstrated between the calyces or the pelvis and the cyst cavity, which was thoroughly e1.1Jlored and cleaned. Many drains were placed and closure accomplished. Postoperatively the patient did very well; she remained afebrile and had a rapidly decreasing amount of drainage. All drains were removed by the eleventh postoperative day when the patient was discharged. Culture of the pus aspirated at surgery revealed Aerobacter aerogenes. Acid fast studies were negative. Microscopic examination of the cyst wall (Dr. Ephriam Woll) revealed fibrous connective tissue containing a few tubular structures lined by a layer of cuboidal cells with a nonspecific, chronic, active, inflammatory reaction.
IXFECTED SOLITARY CYST OF KID:'\EY
DISCUSSION
The etiology of spontaneously infected solitary cysts of the kidney has yet to be definitely established. If one fayors a congenital origin f;r the presence of solitarv with later infection then the possibility of infection either by ~ hematogenous route or direct extension must be considered. In the latter situation, the absence of a direct communication between the cyst and the pelviocalyceal system gives weight to Nelson and Hooper's hypothesis of spread of organisms directly across the tissues and through the cyst wall into the lumen. 1 If we assume that simple cysts can also be acquired, as advanced by Heplcr13 and implied by Greenberg and associates 14 who documented 40 per cent of simple cysts to be associated with other pathologic renal conditions, then the possibility of cystic degeneration in a preexisting renal abscess or carbuncle must be cnkrtaincd. This lesion may be acquired also on the basis of a chronic obliterative pyelonephritis resulting in cystic dilatation of a calyx with subsequent isolation, as described in four cases reported by Hyams and Kenyon. 15 This latter pathogenesis of the disease would account for those cases of infected cysts where a small communication may still exist between the cyst and the collecting system. Such cases in which a communication still exists am not true solitary and are better classified as pyelogenic ·s
Hepler, A. R. Surg., Gynec. & Obst., 50: 668, 1930. 14 Greenberg, B. E., Brodny, M. L. and Robbins. S. A.: Am. J. 8urg., 23: 2711, 1934. ' 15 Hyams, J. A. a.nd Kenyon, H. R.: ,T. Urol. 46: 380, 194L (3
cysts, calyceal di verticula and They may possibly represent an intcrmediat,, state where the inflarn.matory process in the infundibular portion of the calvx has not resulted in complete obstructio~ and isolation of the dilated calyx from the renal pelvis. The diagnosis of infected solitary cyst of tlrn kidney should be suspected vd1en there is e,·i· dence of a space-occupying lesion radiographi. cally together with exquisite pain of renal and high fever. Urinary symptoms need not necessarily be present. Urinary findings are apt to be disappointing. Bacteria ancl leukocytes or may not be present in the urine anci cultlirt:c, may be sterile. Differential diagnosis should include tumors of the kidney, particularly nephroma, polycystic disease, hydrocalycoRi.~ 1 renal carbuncle or abscess and simple c,r"t complicated by pyelonephritis. Treatment is surgical: either incision and drainage with excision of the cyst wall, or ectomy if the lesion is extensive and little renal parenchyma is uninvolved. An adequate course of antibiotic therapy should be tried, since rapid resolution of the mass lesion would make surgery unnecessary or perhaps allow a more conservative operative procedure, as was in this patient.
m;v
SUMMARY
The thirteenth case of a spontaneously infoded solitary cyst of the kidney has been nr,ooont,vl The etiology, diagnosis and treatment of this lesion are discussed with emphasis on use antibiotic therapy in preoperative management and in differential diagnosis.
Vol. 83, No. 1, January 1960 Printed in U.S.A.
INFECTED SOLITARY CYST OF THE KIDNEY STANLEY D. CHOVNICK
AND
DAVID S. SILVERT
From the Departments of Urology, Albert Einstein College of Medicine, Brom; Hospital Center, New York, N. Y. and Danbury Hospital, Danbury, Conn.
Spontaneous infec:tion of solitary cysts of the kidney oceur so infrequently that an adequate description is not readily obtained in standard textbooks. Aside from a recent case report by Nelson and Hooper in 1952, 1 other articles have been relatively rare. H. B. Swecetser2 reported a case in 1929 and gave reference to another case reported by Patel and Mallet-Guy 3 in the same year. Additional cases have been reported as well in the foreign literature by Cassioli in 1917, 4 Bocminghaus in 1935, 5 Botta 11/Iicca in 1930, 6 Fang7 in 1938 and 2 cases by Cibert in 1937. 8 · 9 Llewelyn Davies10 and Daviclson 11 reported cases in 1938 and 1940 respectively with good results after nephrectomy. Chalkley and Sutton12 reported the first and only case in a child bringing the number of cases in the world's literature to twelve. Because of the paucity of reports on this lesion and because of a successful conservative operative approach, the following case is presented.
the right flank and right upper quadrant, which worsened during thP clay, and required hei admission to the hospital by evening. The was clesnibed as being a deep, steady ache with occasional colicky manifestations and loc:11.ecl predominantly in the right upper Fever and chills associated with nausea and vomiting continued throughout the day. Her bowel movements and menstrual periods \1·crr normal. She had no urinary complaints. Pertinent findings in the past history were similar episodes of pain and fover on three previous occasions, in 1951, and 1954 and November 1958. The latter was interprded biliary colic ..-U no time had there been an mologic eYaluation. The patient was confined to sanatorium for 10 months in 1952 and received treatment for pulmonary tuberculosis with streptomycin and PAS. She had been follo1,·ed and found "inactive" on annual examinations since that time. Examination at the time of admission vealed an asthenic, pale, febrile woman obvious discomfort referred to the upper abdc,. men. The abdomen was soft except for mocl(-:rnte guarding, marked tenderness in the right upper quadrant and to a lesser dcigree in the lower quadrant. The left side of the abdomen showed rebound tenderru"ss referred to the right. There was marked right flank and costn. vertebral angle tenderness. Her tempemturc wr~R 102 degrees. The remainder of the examination was not remarkable. Examination of a catheterized urine on admission showed 50--60 white, blood cells and 10-15 red blood cells. Another obtained 24 hours later revealed 3-4 whit;e blood cells with a rare clump and 1--2 reel bloorl cells. The patient's hemoglobin was J 3 gm. pc:r cent, hematocrit 40 per cent, white count with a polymorphonuclcar kukocytosis. Gailbladder ancl gastrointestinal series were essc:ntially negative. The patient was treated with intn.1venmrn foedings, nasogastric suction because of
CASE REPORT
A 27-year-olcl white woman was admitted to the Danbury Hospital on January 23, 1959. She had symptoms of cystitis approximately one week prior to admission and vvas treated by her family physician with alleviation of the symptoms. Early in the morning of the clay of admission, the patient experienced severe colic in Accepted for publication ,June 30, 1959. 1 Nelson, C. B. and Hooper, C. J. Urol., 68: 1952. , H. B.: Minn. 12: 786, 1929. 3 Patel, JV[. and M.: d'nrol., 19: 316, 1925. 4 Cassioli, C.: Revista ospedal, Roma., 7: 151.
J:
1917.
5 Boeminghaus: Ztschr. f. Urol., 29; 191, 1935. "Botta Micca, A.: Riv, san. Siciliana., 18: 1566, 1930. 7 Fang, C. H.: Chin. Med. J 53: 221, 1938. 8 Gibert, J.: J. d'urol., 42: 1937. 9 Ibid. 43: 325, 1987 10 Davies, J. L.: Proc. Roy. Soc. Med., 32: 543, 1938. n Davidson, B.: N. Y. State J. ;VIed., 40: 875, 1940. 12 Chalkley, T. S. iLnd Sutton, L. E., Jr.: J.
Urol., 50: 414, 1943.
7
8
STANLEY D. CHOVNICK AND DAVID S. SILVERT
Fm. 1. Excretory right pyelogram shows incomplete filling of calyceal system with a possible space-occupying lesion in lower pole. and tetracycline therapy. Her temperature ranged daily up to 102 degrees. Although she improved gradually, tenderness and guarding continued mainly in the right upper quadrant. On the sixth hospital day, urologic consultation was obtained. Intravenous pyelograms showed a normally functioning left kidney and incomplete filling of the right calyceal system with a possible space occupying lesion in the lower pole (fig. 1). Cystoscopy demonstrated low grade cystitis with normal appearing ureteral orifices. Urine specimens showed 7-8 white blood cells in the bladder urine and 4-5 red blood cells from the right ureter. Gram positive cocci in pairs and short chains were seen in smears of both bladder and ureteral urine, but no growth resulted in cultures of urine collected both on admission and at the time of cystoscopy. On the basis of the urinary smears, the patient was placed on novobiocin and her temperature coincidentally fell to normal levels. Retrograde pyelograms (fig. 2) showed incomplete filling of the right lower and middle calyces which appeared to be rearranged and distorted. Prior to surgery, an enlarged right kidney could be palpated. Surgery was performed on the tenth hospital day. The perinephric tissues were edematous and the lower pole of the right kidney enlarged two and one-half times. A cystic mass was felt
FrG. 2. Retrograde pyelogram shows rearrangement and distortion of middle and lower calyces with little displacement of transverse colon.
and needle aspiration recovered 75 cc white non-odorous pus. Incision, drainage and excision of the cyst wall were performed and specimens sent for routine and acid fast culture as well as for microscopic pathologic examination. No communication could be demonstrated between the calyces or the pelvis and the cyst cavity, which was thoroughly e1.1Jlored and cleaned. Many drains were placed and closure accomplished. Postoperatively the patient did very well; she remained afebrile and had a rapidly decreasing amount of drainage. All drains were removed by the eleventh postoperative day when the patient was discharged. Culture of the pus aspirated at surgery revealed Aerobacter aerogenes. Acid fast studies were negative. Microscopic examination of the cyst wall (Dr. Ephriam Woll) revealed fibrous connective tissue containing a few tubular structures lined by a layer of cuboidal cells with a nonspecific, chronic, active, inflammatory reaction.
IXFECTED SOLITARY CYST OF KID:'\EY
DISCUSSION
The etiology of spontaneously infected solitary cysts of the kidney has yet to be definitely established. If one fayors a congenital origin f;r the presence of solitarv with later infection then the possibility of infection either by ~ hematogenous route or direct extension must be considered. In the latter situation, the absence of a direct communication between the cyst and the pelviocalyceal system gives weight to Nelson and Hooper's hypothesis of spread of organisms directly across the tissues and through the cyst wall into the lumen. 1 If we assume that simple cysts can also be acquired, as advanced by Heplcr13 and implied by Greenberg and associates 14 who documented 40 per cent of simple cysts to be associated with other pathologic renal conditions, then the possibility of cystic degeneration in a preexisting renal abscess or carbuncle must be cnkrtaincd. This lesion may be acquired also on the basis of a chronic obliterative pyelonephritis resulting in cystic dilatation of a calyx with subsequent isolation, as described in four cases reported by Hyams and Kenyon. 15 This latter pathogenesis of the disease would account for those cases of infected cysts where a small communication may still exist between the cyst and the collecting system. Such cases in which a communication still exists am not true solitary and are better classified as pyelogenic ·s
Hepler, A. R. Surg., Gynec. & Obst., 50: 668, 1930. 14 Greenberg, B. E., Brodny, M. L. and Robbins. S. A.: Am. J. 8urg., 23: 2711, 1934. ' 15 Hyams, J. A. a.nd Kenyon, H. R.: ,T. Urol. 46: 380, 194L (3
cysts, calyceal di verticula and They may possibly represent an intcrmediat,, state where the inflarn.matory process in the infundibular portion of the calvx has not resulted in complete obstructio~ and isolation of the dilated calyx from the renal pelvis. The diagnosis of infected solitary cyst of tlrn kidney should be suspected vd1en there is e,·i· dence of a space-occupying lesion radiographi. cally together with exquisite pain of renal and high fever. Urinary symptoms need not necessarily be present. Urinary findings are apt to be disappointing. Bacteria ancl leukocytes or may not be present in the urine anci cultlirt:c, may be sterile. Differential diagnosis should include tumors of the kidney, particularly nephroma, polycystic disease, hydrocalycoRi.~ 1 renal carbuncle or abscess and simple c,r"t complicated by pyelonephritis. Treatment is surgical: either incision and drainage with excision of the cyst wall, or ectomy if the lesion is extensive and little renal parenchyma is uninvolved. An adequate course of antibiotic therapy should be tried, since rapid resolution of the mass lesion would make surgery unnecessary or perhaps allow a more conservative operative procedure, as was in this patient.
m;v
SUMMARY
The thirteenth case of a spontaneously infoded solitary cyst of the kidney has been nr,ooont,vl The etiology, diagnosis and treatment of this lesion are discussed with emphasis on use antibiotic therapy in preoperative management and in differential diagnosis.