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Perinephritic Abscess in a Case of Horseshoe Kidney
PERINEPHRITIC ABSCESS IN A CASE OF HORSESHOE KIDNEY HENRY S. BROWNE
Tulsa, Oklahoma Received for publication January 22, 1927
Cases of horseshoe kidney that have come to operation and have been reported in the literature are surprisingly rare. We know from the compilation of autopsy reports that it occurs in about 1 in 800 cases. The very great majority of operative cases reported up to now, have been recognized only at operation and in only a few has the diagnosis been made preoperatively. Such have been the advances made by the use of modern urological methods that in the later reports this ratio has been reversed and we may in the future expect such cases to be recognized before operation in nearly every instance where a complete urological examination is made. A plain x-ray plate will often show the isthmus extending across the vertebral column, joining the two halves; and in cases of calculi, the abnormal location of the stone shadows will often help to make the diagnosis. It is on the pyelogram that we must place our main reliance in diagnosis, for the pyelographic picture of a horseshoe kidney is well known. In a review of the literature by Eisendrath, Phifer and Culver (1), they collected a series of 132 cases of horseshoe kidney that had been operated on or come to autopsy up to July, 1925, including 3 cases of their own. Only 19 of these were diagnosed before operation or autopsy and the diagnosis con-firmed. Only 9 were diagnosed by modern urological methods, including their 3 cases. Colston and Scott (2) report 4 cases, 3 of which came to operation and were diagnosed preoperatively; and Kretschmer (3) reports 5 cases diagnosed preoperatively making a total of 27 cases. Due to congenital anomalies it is 85
86
HENRY S. BROW:N"E
a well known fact that horseshoe kidneys are more susceptible to ordinary surgical diseases of the kidney. It was, therefore, a surprise in checking over these 140 cases to find that no case of perinephritic abscess was included. The following case report is, therefore, of interest: F. B. F. was referred on August 20, 1926, by Dr. G. A. Wall for urological study. Dr.Wall, from the history and clinical findings, had made
FIG. 1.
LEFT PYELOGRAM.
SHOWING THE LONG NARROW PELVIS WITH ITS CON-
VEXITY OUTWARD AND WITH MESIALLY DIRECTED CALICES
Note insertion of ureter in front of and to outer side of lowest mesial calyx
a diagnosis of left perinephritic abscess and wished to know if the kidney itself was involved, and the condition of the other kidney. The patient was a farmer, aged thirty-four, and married. His family history was negative. He had had measles and whooping cough as a child and influenza in 1918. His venereal history was negative. He had always
PERINEPHRITIC ABSCESS
87
been a healthy, hard-working farmer up to eight weeks before when he began to have a dull aching pain in the region of his left kidney. This became progressively worse and two weeks later he was forced to go to bed where he remained. He was first seen by Dr. Wall in St. John's Hospital three days before. His pain was always dull and aching in character and strictly localized about the left kidney. He had had fever fairly constantly from the beginning, but no chills. His appetite was very poor and he had lost 30 pounds in eight weeks. For several
FIG. 2.
RIGHT PYELOGRAM,
SHOWING THE
Low
POSITION AND PROXIMITY TO
VERTEBRAL COLUMN OF THIS HALF
Note mcsially directed calices and insertion of ureter in front of one of these
weeks the left thigh had been kept in a flexed position because extension caused pain. He had no burning, frequency or pain on urination and the act was entirely normal. On physical examination the patient was found to be a tall, well-developed man of about thirty-five, very emaciated. The lungs were negative. A systolic murmur was heard at the base of the heart and transmitted upward. The pulse was very
88
HENRY S. BROWNE
weak and 120 to the minute. Examination of the abdomen revealed a rigidity on the left side, more marked above. The thigh was kept in a flexed position. There was definite bulging and pain on palpation in the region of the left kidney. A board-like rigidity was present in this region and a hardness almost simulating malignancy. The leukocyte count was 8500 with 82 per cent neutrophiles. On cystoscopic examination, tho cystoscope entered the bladder after a little manipulation and 60 cc. of clear urine was obtained. This, on centrifuging, showed no pus, blood, casts or bacteria, and on staining the sediment and examining, nothing abnormal was found. The bladder was everywhere found normal. A No. 6 F. catheter entered the right ureter and ascended about one-half way where an obstruction was met. Normal urine was obtained from this side and the phthalein excretion was nor-mal. A No. 5 F. catheter entered the right ureter and ascended to the kidney ·without difficulty. Only a few drops of urine were obtained and only a trace of phthalein was excreted from this side. The left pelvis was then injected with 6 cc. of 13 per cent sodium iodid solution and a pyelogram made. This showed a small upper major calyx with about 6 minor calices emptying by a long, narrow tube into the pelvis. Except for this fact, it resembled the upper part of a bifid pelvis. The pelvis was about in normal position but very long and narrow lying behind and to the outer side of the kidney as shown by the direction of the calices. Several of these were directed rnesially, the lowest one being markedly so. One could almost visualize the isthmus from this calyx. The ureter was inserted in front of and to the outer side of this calyx. The tip of the catheter was in the small upper calyx which explained the poor functional test from this side. The convexity of the pelvis was outward and the outline of the calices was clear cut and normal. With the above pyelographic findings, a diagnosis of horseshoe kidney was made. From the history and clinical findings, a diagnosis was made of left perinephritic abscess without involvement of the kidney, as shown by the urological study. The patient was operated on on August 21, 1926, by Dr. \Vall, assisted by the author, the usual kidney incision being made. About 150 cc. of creamy pus was evacuated from around the kidney which was found to be fixed and immovable. Adhesions were carefully freed to the vertebral column below to which point kidney substance could be palpated. The abscess cavity was packed with iodoform gauze which was removed in fortyeight hours. The patient made a rapid recovery and was discharged from the hospital on the tenth day postoperative, with very little
PERINEPHRITIC ABSCESS
89
drainage at that t.ime. Before his discharge, a right pyelogram was made, which showed the right half of the horseshoe kidney to be very much lower than the left and close to the spine, lying opposite the third, fourth and fifth lumbar vertebrae. Very much the same type of pelvis as on the left side was found. The curious formation of the upper calyx was even more marked. Several calices were directed mosially and the ureter was inserted in front of those.
The diagnosis in the above case of horseshoe kidney was made before operation by pyelography and confirmed at operation. The right pyelogram made after operation further confirmed the diagnosis. I have been unable to find a previous report of perinephritic abscess in a case of horseshoe kidney. This is only additional evidence that those with horseshoe kidney are liable to all the ills of normal man and much more liable to some of the common kidney ills. This case also emphasizes the importance of modern urological methods in the study of surgical diseases. REFERENCES (1) (2) (3)
Ann. Surg., !xxxii, no. 5, 735-765. Jour. Urol., xvi, no. 5, 319-334. Jour. Amer. Med. Assoc., lxxxviii, no. 2, 77-82.
EISENDRATH, PHIFER AND CuLVER: COLSTON A::-!D SCOTT: Km~TSCI-JMER:
Tulsa, Oklahoma Received for publication January 22, 1927
Cases of horseshoe kidney that have come to operation and have been reported in the literature are surprisingly rare. We know from the compilation of autopsy reports that it occurs in about 1 in 800 cases. The very great majority of operative cases reported up to now, have been recognized only at operation and in only a few has the diagnosis been made preoperatively. Such have been the advances made by the use of modern urological methods that in the later reports this ratio has been reversed and we may in the future expect such cases to be recognized before operation in nearly every instance where a complete urological examination is made. A plain x-ray plate will often show the isthmus extending across the vertebral column, joining the two halves; and in cases of calculi, the abnormal location of the stone shadows will often help to make the diagnosis. It is on the pyelogram that we must place our main reliance in diagnosis, for the pyelographic picture of a horseshoe kidney is well known. In a review of the literature by Eisendrath, Phifer and Culver (1), they collected a series of 132 cases of horseshoe kidney that had been operated on or come to autopsy up to July, 1925, including 3 cases of their own. Only 19 of these were diagnosed before operation or autopsy and the diagnosis con-firmed. Only 9 were diagnosed by modern urological methods, including their 3 cases. Colston and Scott (2) report 4 cases, 3 of which came to operation and were diagnosed preoperatively; and Kretschmer (3) reports 5 cases diagnosed preoperatively making a total of 27 cases. Due to congenital anomalies it is 85
86
HENRY S. BROW:N"E
a well known fact that horseshoe kidneys are more susceptible to ordinary surgical diseases of the kidney. It was, therefore, a surprise in checking over these 140 cases to find that no case of perinephritic abscess was included. The following case report is, therefore, of interest: F. B. F. was referred on August 20, 1926, by Dr. G. A. Wall for urological study. Dr.Wall, from the history and clinical findings, had made
FIG. 1.
LEFT PYELOGRAM.
SHOWING THE LONG NARROW PELVIS WITH ITS CON-
VEXITY OUTWARD AND WITH MESIALLY DIRECTED CALICES
Note insertion of ureter in front of and to outer side of lowest mesial calyx
a diagnosis of left perinephritic abscess and wished to know if the kidney itself was involved, and the condition of the other kidney. The patient was a farmer, aged thirty-four, and married. His family history was negative. He had had measles and whooping cough as a child and influenza in 1918. His venereal history was negative. He had always
PERINEPHRITIC ABSCESS
87
been a healthy, hard-working farmer up to eight weeks before when he began to have a dull aching pain in the region of his left kidney. This became progressively worse and two weeks later he was forced to go to bed where he remained. He was first seen by Dr. Wall in St. John's Hospital three days before. His pain was always dull and aching in character and strictly localized about the left kidney. He had had fever fairly constantly from the beginning, but no chills. His appetite was very poor and he had lost 30 pounds in eight weeks. For several
FIG. 2.
RIGHT PYELOGRAM,
SHOWING THE
Low
POSITION AND PROXIMITY TO
VERTEBRAL COLUMN OF THIS HALF
Note mcsially directed calices and insertion of ureter in front of one of these
weeks the left thigh had been kept in a flexed position because extension caused pain. He had no burning, frequency or pain on urination and the act was entirely normal. On physical examination the patient was found to be a tall, well-developed man of about thirty-five, very emaciated. The lungs were negative. A systolic murmur was heard at the base of the heart and transmitted upward. The pulse was very
88
HENRY S. BROWNE
weak and 120 to the minute. Examination of the abdomen revealed a rigidity on the left side, more marked above. The thigh was kept in a flexed position. There was definite bulging and pain on palpation in the region of the left kidney. A board-like rigidity was present in this region and a hardness almost simulating malignancy. The leukocyte count was 8500 with 82 per cent neutrophiles. On cystoscopic examination, tho cystoscope entered the bladder after a little manipulation and 60 cc. of clear urine was obtained. This, on centrifuging, showed no pus, blood, casts or bacteria, and on staining the sediment and examining, nothing abnormal was found. The bladder was everywhere found normal. A No. 6 F. catheter entered the right ureter and ascended about one-half way where an obstruction was met. Normal urine was obtained from this side and the phthalein excretion was nor-mal. A No. 5 F. catheter entered the right ureter and ascended to the kidney ·without difficulty. Only a few drops of urine were obtained and only a trace of phthalein was excreted from this side. The left pelvis was then injected with 6 cc. of 13 per cent sodium iodid solution and a pyelogram made. This showed a small upper major calyx with about 6 minor calices emptying by a long, narrow tube into the pelvis. Except for this fact, it resembled the upper part of a bifid pelvis. The pelvis was about in normal position but very long and narrow lying behind and to the outer side of the kidney as shown by the direction of the calices. Several of these were directed rnesially, the lowest one being markedly so. One could almost visualize the isthmus from this calyx. The ureter was inserted in front of and to the outer side of this calyx. The tip of the catheter was in the small upper calyx which explained the poor functional test from this side. The convexity of the pelvis was outward and the outline of the calices was clear cut and normal. With the above pyelographic findings, a diagnosis of horseshoe kidney was made. From the history and clinical findings, a diagnosis was made of left perinephritic abscess without involvement of the kidney, as shown by the urological study. The patient was operated on on August 21, 1926, by Dr. \Vall, assisted by the author, the usual kidney incision being made. About 150 cc. of creamy pus was evacuated from around the kidney which was found to be fixed and immovable. Adhesions were carefully freed to the vertebral column below to which point kidney substance could be palpated. The abscess cavity was packed with iodoform gauze which was removed in fortyeight hours. The patient made a rapid recovery and was discharged from the hospital on the tenth day postoperative, with very little
PERINEPHRITIC ABSCESS
89
drainage at that t.ime. Before his discharge, a right pyelogram was made, which showed the right half of the horseshoe kidney to be very much lower than the left and close to the spine, lying opposite the third, fourth and fifth lumbar vertebrae. Very much the same type of pelvis as on the left side was found. The curious formation of the upper calyx was even more marked. Several calices were directed mosially and the ureter was inserted in front of those.
The diagnosis in the above case of horseshoe kidney was made before operation by pyelography and confirmed at operation. The right pyelogram made after operation further confirmed the diagnosis. I have been unable to find a previous report of perinephritic abscess in a case of horseshoe kidney. This is only additional evidence that those with horseshoe kidney are liable to all the ills of normal man and much more liable to some of the common kidney ills. This case also emphasizes the importance of modern urological methods in the study of surgical diseases. REFERENCES (1) (2) (3)
Ann. Surg., !xxxii, no. 5, 735-765. Jour. Urol., xvi, no. 5, 319-334. Jour. Amer. Med. Assoc., lxxxviii, no. 2, 77-82.
EISENDRATH, PHIFER AND CuLVER: COLSTON A::-!D SCOTT: Km~TSCI-JMER: