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Perinephritic Abscess: Review of a Series of Cases1
PERINEPHRITIC ABSCESS REVIEW OF A SERIES OF CASES1 HARRY C. ROLNICK
AND
H. J. BURSTEIN
From the Department of Urology, Cook County Hospital, Chicago, Illinois
The remark of a prominent internist that he had recently seen 3 cases of perinephritic abscess but had failed to make a diagnosis in 2 of these until the condition became frank, prompted us to review this series. We were impressed with the difficulties this condition presents on diagnosis and the rather long interval between the onset of symptoms and operation. We shall make no attempt to review this subject completely for the literature on perinephritic abscess is already quite extensive (1). Within the last decade, a number of excellent reports have appeared in the European and American literature covering reviews of large series of cases (2, 3). A few of these which have appeared recently are quite complete. One author reviewed 1500 reported cases (4) and another covered the subject in detail (5). We were particularly interested in the diagnosis of the metastatic forms of perinephritic abscess. Those that develop secondary to previous infections of the kidney present relatively little difficulty in diagnosis, for the history, symptoms and clinical evidence direct the attention to the kidney. The records of Cook County Hospital of the last five years were assembled and analyzed. Fifty-five cases are here reported. Perinephritic abscess or para-nephritic abscess, the designation most frequently employed in the European literature and probably more correct, is relatively uncommon. As indicated, an average of eleven cases a year were seen in one of the largest general hospitals in the world. Although this review presents very little that is new and mentions the more recent diagnostic 1
Read before the Chicago Urological Society, May 22, 1930.
507
508
HARRY C. ROLNICK AND H. J. BURSTEIN
radiographic findings in but a few instances, some selected cases of this series are of interest. A number of the patients entered the hospital with definite evidence of tumor mass and bulging in the loin so that the diagnosis could be made readily in the admitting room. Most, however, required a varying interval from a few days to eight or ten weeks of study before a diagnosis could be made. All the cases that could be studied presented evidence of fever, which was usually prolonged, and a fairly marked leucocytosis varying from 12,000 to 35,000; also in most instances costovertebral or abdominal tenderness which usually appeared early. These constitute, as one author has noted, the triad of early symptoms and signs of the disease (6). Of this series, 21 gave a history of previous renal disease or showed evidences of old kidney involvement. Two followed direct injury to the back and abdomen, and another was secondary to a retro-cecal appendicitis with abscess which perforated retro-peritoneally and then extended upward. The other 31 were apparently metastatic in origin, although the foci of infection could not be determined in every case. Four of 5 cases, in which the diagnosis of perinephritic abscess had been made, proved later after some study to be either pyonephrosis or calculous kidney,-the fifth case was entirely negative at operation. Most of the patients were between thirty and forty; the youngest was four and the oldest was sixty-eight; 3 were under ten and 6 between ten and twenty; there were 44 white and 11 negro; 39 male and 16 female. Seven of the 55 patients died, 2 of these following nephrectomy as a secondary operation, so that the actual number of deaths due to perinephritic abscess can be listed as 5. One patient, who had been sick for three weeks, died a few minutes after entering the hospital. On post-mortem she showed an extensive perinephritic abscess. Another patient died within twenty-four hours after admittance, giving a history of having been well until the sudden onset of chill and sweat six hours previously and presented diffuse abdomi'nal rigidity and tenderness. Postmortem here showed perinephritic abscess with peritonitis.
PERINEPHRITIC ABSCESS
509
This case is interesting. This patient had a perinephritic abscess which was apparently of rather long duration but produced no symptoms until it had suddenly perforated the peritoneum. A third patient, who died two days after operation, showed post-mortem a perforated retro-cecal appendicitis and perinephritic abscess which resulted from extension of the appendiceal abscess and presented also bilateral polycystic kidneys. A fourth patient was not diagnosed ante-mortem and was not operated upon. He was treated for septicemia showing Streptococcus viridans on blood culture. On post-mortem there was extensive renal pathology on one side with perinephritic abscess. His stay in the hospital was seventeen days. There were no urinary symptoms nor findings. The fifth death gave a history of having had pain in the right costo-vertebral region for eight weeks before entering the hospital. She was not operated upon until one month later, an interval of three months between onset of symptoms and operation, and died three weeks after operation of exhaustion and sepsis. Four patients refused operation and left the hospital within a few days after admission. They were, however, clinically obvious cases. One cleared up without operation; his stay in the hospital was thirteen weeks; he had had fever and chills for two weeks previous to entry; onset of pain followed injury due to beating and kicking in abdomen and back. This patient ran a septic temperature, had a soft bulging mass in the right loin from which, however, no pus could be aspirated. This was evidently a hematoma of the peri-renal tissues with a low grade secondary infection that gradually cleared up. A number of the metastatic or hematogenous infections were readily diagnosed upon admission. These showed definite evidence of bulging in the loin with a history of chills, fever and localized pain for three to eight weeks before entering the hospital. Most of the cases required a period of observation, extending from two to eight weeks after admission, before operation and drainage were instituted. It is in this latter group of metastatic perinephritic abscess that diagnosis was often arrived at with
510
HARRY C. ROLNICK AND H. J . BURSTEIN
difficulty and usually quite late, very often not until definite bulging appeared in the loin. They- the metastatic infections- usually present vague symptoms with localization of the pain in most cases only after many days or weeks. These patients presented symptoms of general toxemia with chills, fever, sweats, rapid emaciation and tenderness, and with vague or indefinite localization of pain and negative urinary findings. Because of this, such conditions as typhoid fever, pleurisy, broncho-pneumonia, osteomyelitis, carcinoma of the stomach, sacroiliac arthritis, malignant endocarditis and pulmonary tuberculosis were mistakenly diagnosed at first, or until definite tumor appeared. In many instances, however, the history of sudden onset with chill, fever and localized pain in the back immediately carried with it the suspicion of renal involvement. The condition that most frequently required differential diagnosis and in some cases differentiated only at operation, was retro-cecal appendicitis. Repeated, careful investigation of the urinary tract,- urinalysis, cystoscopy and pyelograms were usually negative during the early weeks of the metastatic infections. The complete absence of urinary findings in most of these cases make the diagnosis very difficult at first. The radiographic evidences of the obscuring of the lateral border of the psoas, by the abscess which is considered diagnostic (7), could not be demonstrated in 4 cases in which it was looked for. However, in a number of cases delayed excursion elevation and rigidity of the diaphragm on the side affected was noted. This finding is of considerable diagnostic value, although it can be mistaken for a subphrenic abscess. The most valuable diagnostic aid in this series was diagnostic puncture and. aspiration. This procedure has been condemned by one author because of the danger of needling the kidney and spreading the infection into the kidney. This objection seems theoretical to us in view of the fact that most authorities are of the opinion that the vast majority of metastatic perinephritic
PERINEPHRITIC ABSCESS
511
abscesses are secondary to extension from metastatic infarcts of the kidney to the perinephritic tissues. Of 12 cases in which it is noted, puncture and aspiration were positive in 8 and determined the diagnosis. It was negative in 1 case that showed a large amount of pus at operation and in another previously mentioned which cleared up without operation. In 2 cases where puncture was negative, the absence of perinephritic abscess was later confirmed on cystoscopy in 1 case and at operation in another. We are impressed with the value of diagnostic puncture as an early aid in diagnosis. In six cases in which the pus from the abscess was examined, 2 were B. coli, 2 Staphylococcus albus, 1 was pneumococcus and 1 Staphylococcus hemolyticus. Blood cultures were positive in 2 cases, 1 showed Staphylococcus albus and the other Streptococcus viridans. Most of the reports show the staphylococcus as the offending agent in the hematogenous infections. Most of the metastatic infections were secondary to furuncles, carbuncles or infections of superficial tissues. Two cases of hand infections are noted; a mosquito bite on the leg in 1 case preceded the development of the perinephritic abscess. A number of infections followed "colds" and upper respiratory infections. One case is almost a classical laboratory experiment. A child of eight had been kicked in the right costo-vertebral region three weeks before entering the hospital. He was vaccinated a few days later, this vaccination wound becoming infected; five days before entering the hospital he began to have chills, fever, tenderness and rigidity in the right costo-vertebral region and developed a mass which was operated upon four days after admission.
31 N. State Street, Chicago, Illinois. REFERENCES (1) BRAASCH: Perinephritic abscess.
Surg. Gynecol. and Obstet., 1915, xxi,
631.
(2) HUNT: Jour. Amer. Med. Assoc., December 27, 1924, p. 2070. (3) PEACOCK, A. H.: Perinephritic abscess. Surg. Gynecol., and Obstet., June, 1929, xlviii, 757.
512 (4)
HARRY C. ROLNICK AND H. J. BURSTEIN
Clinical aspects of suppurative perinephritis. Trans. Russian Surg. Cong., Moscow, 1928, abstracted in Surg. Gynecol. and Obstet., May, 1930. (5) FRIEDRICH: Clinical aspects and diagnosis of paranephritic abscess. Zeitsschrift fur Urolog. Chir., 1929, xv, 28. (6) HABEIN, H . C.: Minnesota Medicine, 1928, ii, 292 . (7) BEER, E.: Roentgenographic evidence of perinephritic abscess. Jour. Amer. Med. Assoc ., April 28, 1928, xc, 1375. BLUMENTHAL :
AND
H. J. BURSTEIN
From the Department of Urology, Cook County Hospital, Chicago, Illinois
The remark of a prominent internist that he had recently seen 3 cases of perinephritic abscess but had failed to make a diagnosis in 2 of these until the condition became frank, prompted us to review this series. We were impressed with the difficulties this condition presents on diagnosis and the rather long interval between the onset of symptoms and operation. We shall make no attempt to review this subject completely for the literature on perinephritic abscess is already quite extensive (1). Within the last decade, a number of excellent reports have appeared in the European and American literature covering reviews of large series of cases (2, 3). A few of these which have appeared recently are quite complete. One author reviewed 1500 reported cases (4) and another covered the subject in detail (5). We were particularly interested in the diagnosis of the metastatic forms of perinephritic abscess. Those that develop secondary to previous infections of the kidney present relatively little difficulty in diagnosis, for the history, symptoms and clinical evidence direct the attention to the kidney. The records of Cook County Hospital of the last five years were assembled and analyzed. Fifty-five cases are here reported. Perinephritic abscess or para-nephritic abscess, the designation most frequently employed in the European literature and probably more correct, is relatively uncommon. As indicated, an average of eleven cases a year were seen in one of the largest general hospitals in the world. Although this review presents very little that is new and mentions the more recent diagnostic 1
Read before the Chicago Urological Society, May 22, 1930.
507
508
HARRY C. ROLNICK AND H. J. BURSTEIN
radiographic findings in but a few instances, some selected cases of this series are of interest. A number of the patients entered the hospital with definite evidence of tumor mass and bulging in the loin so that the diagnosis could be made readily in the admitting room. Most, however, required a varying interval from a few days to eight or ten weeks of study before a diagnosis could be made. All the cases that could be studied presented evidence of fever, which was usually prolonged, and a fairly marked leucocytosis varying from 12,000 to 35,000; also in most instances costovertebral or abdominal tenderness which usually appeared early. These constitute, as one author has noted, the triad of early symptoms and signs of the disease (6). Of this series, 21 gave a history of previous renal disease or showed evidences of old kidney involvement. Two followed direct injury to the back and abdomen, and another was secondary to a retro-cecal appendicitis with abscess which perforated retro-peritoneally and then extended upward. The other 31 were apparently metastatic in origin, although the foci of infection could not be determined in every case. Four of 5 cases, in which the diagnosis of perinephritic abscess had been made, proved later after some study to be either pyonephrosis or calculous kidney,-the fifth case was entirely negative at operation. Most of the patients were between thirty and forty; the youngest was four and the oldest was sixty-eight; 3 were under ten and 6 between ten and twenty; there were 44 white and 11 negro; 39 male and 16 female. Seven of the 55 patients died, 2 of these following nephrectomy as a secondary operation, so that the actual number of deaths due to perinephritic abscess can be listed as 5. One patient, who had been sick for three weeks, died a few minutes after entering the hospital. On post-mortem she showed an extensive perinephritic abscess. Another patient died within twenty-four hours after admittance, giving a history of having been well until the sudden onset of chill and sweat six hours previously and presented diffuse abdomi'nal rigidity and tenderness. Postmortem here showed perinephritic abscess with peritonitis.
PERINEPHRITIC ABSCESS
509
This case is interesting. This patient had a perinephritic abscess which was apparently of rather long duration but produced no symptoms until it had suddenly perforated the peritoneum. A third patient, who died two days after operation, showed post-mortem a perforated retro-cecal appendicitis and perinephritic abscess which resulted from extension of the appendiceal abscess and presented also bilateral polycystic kidneys. A fourth patient was not diagnosed ante-mortem and was not operated upon. He was treated for septicemia showing Streptococcus viridans on blood culture. On post-mortem there was extensive renal pathology on one side with perinephritic abscess. His stay in the hospital was seventeen days. There were no urinary symptoms nor findings. The fifth death gave a history of having had pain in the right costo-vertebral region for eight weeks before entering the hospital. She was not operated upon until one month later, an interval of three months between onset of symptoms and operation, and died three weeks after operation of exhaustion and sepsis. Four patients refused operation and left the hospital within a few days after admission. They were, however, clinically obvious cases. One cleared up without operation; his stay in the hospital was thirteen weeks; he had had fever and chills for two weeks previous to entry; onset of pain followed injury due to beating and kicking in abdomen and back. This patient ran a septic temperature, had a soft bulging mass in the right loin from which, however, no pus could be aspirated. This was evidently a hematoma of the peri-renal tissues with a low grade secondary infection that gradually cleared up. A number of the metastatic or hematogenous infections were readily diagnosed upon admission. These showed definite evidence of bulging in the loin with a history of chills, fever and localized pain for three to eight weeks before entering the hospital. Most of the cases required a period of observation, extending from two to eight weeks after admission, before operation and drainage were instituted. It is in this latter group of metastatic perinephritic abscess that diagnosis was often arrived at with
510
HARRY C. ROLNICK AND H. J . BURSTEIN
difficulty and usually quite late, very often not until definite bulging appeared in the loin. They- the metastatic infections- usually present vague symptoms with localization of the pain in most cases only after many days or weeks. These patients presented symptoms of general toxemia with chills, fever, sweats, rapid emaciation and tenderness, and with vague or indefinite localization of pain and negative urinary findings. Because of this, such conditions as typhoid fever, pleurisy, broncho-pneumonia, osteomyelitis, carcinoma of the stomach, sacroiliac arthritis, malignant endocarditis and pulmonary tuberculosis were mistakenly diagnosed at first, or until definite tumor appeared. In many instances, however, the history of sudden onset with chill, fever and localized pain in the back immediately carried with it the suspicion of renal involvement. The condition that most frequently required differential diagnosis and in some cases differentiated only at operation, was retro-cecal appendicitis. Repeated, careful investigation of the urinary tract,- urinalysis, cystoscopy and pyelograms were usually negative during the early weeks of the metastatic infections. The complete absence of urinary findings in most of these cases make the diagnosis very difficult at first. The radiographic evidences of the obscuring of the lateral border of the psoas, by the abscess which is considered diagnostic (7), could not be demonstrated in 4 cases in which it was looked for. However, in a number of cases delayed excursion elevation and rigidity of the diaphragm on the side affected was noted. This finding is of considerable diagnostic value, although it can be mistaken for a subphrenic abscess. The most valuable diagnostic aid in this series was diagnostic puncture and. aspiration. This procedure has been condemned by one author because of the danger of needling the kidney and spreading the infection into the kidney. This objection seems theoretical to us in view of the fact that most authorities are of the opinion that the vast majority of metastatic perinephritic
PERINEPHRITIC ABSCESS
511
abscesses are secondary to extension from metastatic infarcts of the kidney to the perinephritic tissues. Of 12 cases in which it is noted, puncture and aspiration were positive in 8 and determined the diagnosis. It was negative in 1 case that showed a large amount of pus at operation and in another previously mentioned which cleared up without operation. In 2 cases where puncture was negative, the absence of perinephritic abscess was later confirmed on cystoscopy in 1 case and at operation in another. We are impressed with the value of diagnostic puncture as an early aid in diagnosis. In six cases in which the pus from the abscess was examined, 2 were B. coli, 2 Staphylococcus albus, 1 was pneumococcus and 1 Staphylococcus hemolyticus. Blood cultures were positive in 2 cases, 1 showed Staphylococcus albus and the other Streptococcus viridans. Most of the reports show the staphylococcus as the offending agent in the hematogenous infections. Most of the metastatic infections were secondary to furuncles, carbuncles or infections of superficial tissues. Two cases of hand infections are noted; a mosquito bite on the leg in 1 case preceded the development of the perinephritic abscess. A number of infections followed "colds" and upper respiratory infections. One case is almost a classical laboratory experiment. A child of eight had been kicked in the right costo-vertebral region three weeks before entering the hospital. He was vaccinated a few days later, this vaccination wound becoming infected; five days before entering the hospital he began to have chills, fever, tenderness and rigidity in the right costo-vertebral region and developed a mass which was operated upon four days after admission.
31 N. State Street, Chicago, Illinois. REFERENCES (1) BRAASCH: Perinephritic abscess.
Surg. Gynecol. and Obstet., 1915, xxi,
631.
(2) HUNT: Jour. Amer. Med. Assoc., December 27, 1924, p. 2070. (3) PEACOCK, A. H.: Perinephritic abscess. Surg. Gynecol., and Obstet., June, 1929, xlviii, 757.
512 (4)
HARRY C. ROLNICK AND H. J. BURSTEIN
Clinical aspects of suppurative perinephritis. Trans. Russian Surg. Cong., Moscow, 1928, abstracted in Surg. Gynecol. and Obstet., May, 1930. (5) FRIEDRICH: Clinical aspects and diagnosis of paranephritic abscess. Zeitsschrift fur Urolog. Chir., 1929, xv, 28. (6) HABEIN, H . C.: Minnesota Medicine, 1928, ii, 292 . (7) BEER, E.: Roentgenographic evidence of perinephritic abscess. Jour. Amer. Med. Assoc ., April 28, 1928, xc, 1375. BLUMENTHAL :