Perinephritic abscess

PERINEPHRITIC CONFUSED

WITH

ADJACENT

ABSCESS OSSEOUS LESIONS*

ERNEST E. KESSLER, M.D., FREDERICK A. BENNETTS, M.D. AND SAMUEL K. BACON, M.D. LOS ANGELES,

F

ROM a standpoint of earIy diagnosis perinephritic abscess is one of the most confusing entities for the reason that this condition is often comphcated by Iack of positive findings andjby the presence of adjacent pathoIogica1 Iesions giving signs and symptoms simiIar or aImost identica1 with those of such an abscess. This report is made to emphasize one of these factors, nameIy bone Iesions in this area. Of 81 suspected cases of perinephritic abscess reviewed, 37 proved to be such either at operation or necropsy. In 3 of the remainder surgery reveaIed a bony Iesion instead of the suspected perirena1 abscess. Preoperative diagnosis of an abscess around the kidney is based upon the folIowing signs and symptoms: pain and tenderness in the costovertebra1 angIe, fever, Ieucocytosis and positive x-ray deviations. Other Iess important findings may be present, such as fixity and sIight Aexion of the thigh due to reffex contracture of the psoas magnus from irritation, IateraI curvature of the spine away from the invoIved side, and the presence of staphyIococci with onIy a few or no pus ceIIs in the urine. Advanced cases predominate in pubIic institutions. These do not prove especiaIIy difhcuIt to diagnose in contradistinction to those earIier abscesses or suppurative conditions usuaIIy observed in private practice, in which the honeycombed fat has not entireIy broken down. The most common site of the abscess is posterior to the kidney with a downward extension. In chiIdren it is apt to be high up toward the median Iine. If pus coIIects near the upper poIe, symptoms wiI1 be * From the Department

CALIF.

simiIar to those of a subphrenic abscess and the diaphragmatic excursion is apt to be considerabIy Iimited. Pleurisy, empyema and even Iung abscess may resuIt by extension of the inffammatory process. Figure I iIIustrates such a case, in which bismuth paste injected into the perinephritic sinus was coughed up through the bronchus. The roentgenoIogica1 studies were disappointing because of the frequent absence of positive or heIpfu1 findings. Stereoscopic pictures as recommended by Peacock heIp in that they may show the kidney dispIaced anteriorIy or IateraIIy by the abscess. Pain is generaIIy IocaIized over the however, it may occur at kidney region; especiaIIy in the inferior a distance, quadrants of the abdomen. The rigidity of the abdomina1 muscIes in chiIdren is most frequentIy due to fear. In aduIts these muscIes are reIaxed unIess the abscess is Iarge, extends anteriorly or has perforated into the abdomina1 cavity. An advanced condition is accompanied by rigidity of the Iumbar muscIes and in an occasiona case a Iarge abscess may show Auctuation. Symptoms of nausea or vomiting are the resuIts of tension on the kidney pedicIe, toxicity, peritonea1 irritation or rarely back pressure in the renaI peIvis when associated with uretera obstruction. Except for the presence of staphyIococci negative urinary findings are the ruIe when the renaI parenchyma is not invoIved. With few exceptions this organism predominates in these infections. Trauma, aIthough often cited as antedating the abscess, is onIy an incident in the course of the disease. The presence of furuncIes, pustuIar acne, paronychia, cutaneous abrasions or other superficia1 foci of infection

of UroIogy, Los Angeles General HospitaI. October, 1932.

223

Read before the Los AngeIes SurgicaI

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in estabhshing the are of assistance diagnosis. The dificulty in establishing a concIusive

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space. They iIlustrate the diff&Ity and confusion which may resuIt when such a condition exists.

FIG. I. Perinephritic sinus injected with bismuth paste, coughed up through bronchus.

preoperative diagnosis is emphasized by the fact that abscesses in this region have been found which Iacked the cIassica1 signs and symptoms of such a condition. Where the majority of signs and symptoms of perinephritic abscess are present and other pathoIogica1 conditions have been reasonably excIuded, surgica1 expIoration is justified. The end resuIts without drainage are exceedingly serious, but when earIy drainage is instituted a cure is the ruIe. In the differentia1 diagnosis of perinephritic abscess, invoIvement of bony structures adjacent to the kidney must aIways be considered. The signs and symptoms in both instances are those of a deep suppuration and the predominant x-ray findings are negative in both. The 3 cases here presented were al1 suspected of being perinephritic abscess. The primary Iesion, however, proved to be suppuration of nearby bony structures without invoIvement of the true perirena1

FIG. 2. Sinus injected with lipiodol and Ieading to tenth rib, showing osteomyelitis.

CASE I. IHospital No. 233-740. A ho? years of age presented himself at the Los AngeIes Genera1 HospitaI on August 16,

twelve

of pain over the left loin, region, fever, anorexia and nausea. For the past month he had had a series of boiIs about the face and trunk. Three weeks ago he had faIIen and sustained a bruise in the region of the Ieft kidney. TweIve days before entry he deveIoped a cough and fever which persisted for three or four days. FoIlowing this he felt unusually we11 up to two days before entry when he compIained of having strained his Ieft side whiIe playing ball. Fever, maIaise, anorexia and severe pain in the left Ioin promptIy ensued. On the day of entry the mother had noted a tender swelling in the painfuI region. She consuIted a physician who referred her to the hospita1. Just before arriving the patient vomited considerabIe biIe-tinged materia1.

1932 complaining sweIIing in this

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Past History: He had had pneumonia twice, measles and smallpox a11 within the past five years. The famiIy history wrs irrelevant. Examination revealed a fairIy we&nourished, weII-deveIoped boy Iying on his back with thighs fIexed. A purulent bIoody drainage exuded from a smaII furuncle Iocated over the right frontal prominence. The nasopharynx was hyperemic. There was a rounded, tender, non-ffuctuant swelIing extending over the Ieft lower ribs posteriorly and laterally and downward to just above the iliac crest. Tenderness was most marked over the costovertebra1 angle. The chest was otherwise normaI. Voluntary- rigidity of the abdomina1 muscIes precIuded a satisfactory examination of the abdomen. Hyperextension and internal rotation of the Ieft thigh did not produce discomfort. The temperature on admission was IOI .8’F., pulse 132, respiration 24 and blood pressure 138192. BIood count showed 30,000 Ieucocytes of which 89 per cent were poIymorphonucIears; red bIood celIs were 4390,oo with 85 per cent hemoglobin. PhenoIsuIphonphthaIein intravenousIy appeared in thirteen minutes and 40 per cent was excreted within the first haIf hour thereafter. UrinaIysis showed a few pus ceIIs, an occasiona red bIood ceI1 and a few gram positive cocci. Non-protein nitrogen of the bIooc1 was 3 I. A flat x-ray pIate of the abdomen showed the kidney outIines and the margins of the psoas muscles obscured by a Iarge amount of intestinal gas; the diaphragm was in its norma position. Diagnosis: Left perinephritic abscess. Operation: Surgical expIoration carried out on August 17, 1932. Through a short hockeystick incision the kidney was compIeteIy mobilized and the diaphragm, kidney fossa and spinal coIumn were carefuIIy expIored. No suppuration was found. Course: X-ray of the chest taken the da3 foIIowing surgery showed some haziness and increased density over the Ieft thorax, suggestive of a smaI1 ac.cumuIation of fluid at the base. Thoracentesis was done and 5 C.C. of opaIescent fIuid aspirated. Examination of this showed a large number of pus ceIIs but no organism. For five days foIIowing operation there was some improvement. Pain, tenderness and fever decreased. Laboratory data obtained during this interva1 showeci a positive bIood cuIture for StaphyIococcus aureus, bIood sugar of 107, negative hIood Wassermann and Kahn reactions, antf a Ieucocytosis of 28,900.

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On August 23 the temperature rose again, pain and tenderness increased and during the next eight days the sweIIing over the lower Ieft ribs posteriorly, previousIy noted, became Ructuant. The mass was incised and approximateI) 300 C.C. of thick pus containing StaphyIOCOCCUS aureus were recovered. FoIIowing drainage the abscess cavity was injected with Iipiodol and x-rays demonstrated a sinus Ieading from the point of incision to a zone of Iocafized bone destruction and periostea1 proIiferation in the IateraI portion of the tenth rib, characteristic of OsteomyeIitis. (See Fig. 2.) After an interva1 of three weeks the necrotic portion of this rib was resected. The patient was discharged from the hospital on October I I, in good condition. Here we have the preoperative picture of a tender area in the Ieft costovertebra1 angle and the Iower chest, fever, poIymorphonucIear Ieucocytosis and a history of a series of furuncIes. There was buIging in the Ioin. The urine showed a smaI1 number of pus ceIIs and a few gram-positive cocci arranged in groups. Other than a soft was tissue sweIIing, the roentgenogram essentiaIIy negative. The dome of the diaphragm and the psoas outIine were observed. ExpIoration of the kidney fossa seemed indicated and was done. Since surgery and repeated x-ray studies did no further not establish a diagnosis, progress was made until an area of ceIIuIitis and fluctuation appeared over the Costa1 margin in the anterior axiIIary Iine of the Ieft chest. Then an x-ray study showed an osteomyeIitis of the left tenth rib. CGX II. HospitaI No. P. F. I +~oo. An eighteen->-ear-old American school by)? presented himseIf in April, 1931, complammg of pain in the Ieft Ioin of two necks’ duration. Tflis pain flegan whiIe pIa\-ing ball and was sflarp at the outset and constant since, racfiating downward into the testicle. Muscular effort aggravated it. There were no chills or urinary symptoms. He had had mumps four weeks before the onset of the present illness. E.vamination reveaIed moderate tenderness and muscular rigidity in the Ieft costovertebral angle. Temperature was irreguIar and septic in type ranging from 98” to 103.6~~. The urine contained gram-positive cocci in groups and singly. There KAS a poI>-morphonuclear Icuco-

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cytosis. A flat x-ray pIate of the abdomen showed obhteration of the Ieft kidney shadow and psoas margin. Diagnosis: Perinephritic abscess. Operation: The Ieft kidney region expIored through a cIassica1 kidney incision. The kidney and perinephritic tissue appeared normaI, but a Iarge abscess was found posterior to the Iumbar fascia, which was incised and drained. Smear and cuhure of the pus showed StaphyIococcus aureus. Because of persistent drainage from the wound a kidney study was performed five weeks after operation. Pus and gram-negative baciIIi were recovered from both kidney pelves. X-rays taken of this region six weeks after operation showed erosion of the margins of the first and second Iumbar vertebrae anteriorIy, with IocaIized destruction of the intervertebra disc. Recovery was compIete. AIthough primary osteomyehtis of the vertebra is rare it is more frequentIy found than OsteomyeIitis of the rib. In January, Lazarus reported 2 cases of this ‘932, condition simuIating perinephritic abscess.

CASE III. HospitaI No. 183-619. A twentyfive year old American housewife entered the hospita1 in October, 1931 with a history of recurring boiIs of the face and neck. Five days before entry she was taken suddenIy III with a pain in the right Ioin. This was fohowed by chihs, fever, night sweats and anorexia. The pain was fairIy constant and radiated downward into the thigh. FIexion reIieved it. Examination reveaIed a weII-deveIoped femaIe showing sIight emaciation. There was extreme tenderness in the right costovertebra1 angIe with a suggestion of a mass there. The temperature was high and septic in type. Leucocytosis was marked with a predominance of poIymorphonucIear ceIIs. The urine contained a few pus ceIIs and gram-negative baciIIi. The first x-ray pIate of the abdomen, taken soon after admission, showed obhteration of the kidney shadows and psoas margins. A tentative diagnosis of perinephritic abscess was made but surgery was postponed in favor of further study. Course: X-rays repeated one week after admission showed erosion of the articuIar process between the third and fourth Iumbar vertebrae. Eighteen days after entrance a Iluctuant mass was obvious on paIpation situated over the right psoas muscIe at the IeveI of the second and third vertebrae. This was drained through a vertica1 incision in the

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right paravertebra1 Iine. StaphyIococcus aureus was demonstrated in the pus. Guinea-pig inocuIation was negative for tubercIe baciIIi. The spine was the origin of this suppurative process.

CONCLUSIONS I. Pathologica processes presenting practicaIIy a11 the signs and symptoms of perinephritic abscess may lie entirely outside the kidney fossa. 2. EarIy accurate diagnosis in such cases with our present procedures is hardly to be expected. 3. When surgical expIoration for perinephritic abscess is unsuccessfu1 a careful consideration and diagnostic investigation of a11 structures adjacent to the kidney shouId be made. 4. Suppuration in this region of structures other than the kidney and perinephritic fat have the same etioIogica1 infection background, viz., hematogenous from foci of suppuration eIsewhere, and such cases occur with sufficient frequency to warrant their consideration in cases of suspected perinephritic abscess. DISCUSSION DR. ROBERT V. DAY: Notwithstanding the rarity of primary osteomyeIitis of rib or vertebra adjacent to the renaI region and producing signs and symptoms resembIing perinephritic abscess, it is important that such conditions be carefuIIy reported because they are apt to Iead to great confusion in diagnosis and subsequent treatment. Appraisal of the nature and manifestations of such lesions wiI1 cause one to consider carefully the possibiIity of its presence. DR. PHILIP STEPHENS: These cases present an interesting probIem of rare bone Iesions simuIating a reIativeIy common kidney lesion. In both instances the origin usuaIIy is from a septic focus. The earIy symptoms are characteristic of generalized septic infection and even the Iater IocaIizing signs are not definite. In retrospect, we might be better able to differentiate these cases if we wouId pay speciaI attention to paIpation directIy aIong the Iine of the ribs for periostea1 tenderness, and in the young person with an abnormal amount of eady psoas invoIvement and pain on IateraI and forward bending we should suspect bone pathoIogy in the spine rather than in the soft tissues about the kidney.