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Primary Unilateral Renal Actinomycosis: Case Report
Vol. 103, Feb. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1970 by The Williams & Wilkins Co.
PRINIARY UNILATERAL RENAL ACTINOiVIYCOSIS: CASE REPORT MELVYN ANHALT
AND
RUSSELL SCOTT, JR.
From the Cora ancl Webb Macling Division of Urology, Department of Surgery, Baylor University Colleg~ of Medicine, Houston, Texas
The first case of solitary renal actinomycosis was described in 1878. Whisenand and Moore reviewed the literature in 1951 and reported the sixteenth case of primary renal actinomycosis.1 Willson-Pepper reviewed the literature and stated that primary actinomycosis occurs in 3 forms: I) chronic suppurative lesions resembling a carbuncle, 2) pyelonephritis and 3) pyonephrosis. 2 Reported cases have shown that there is a great propensity toward abscess and sinus tract formation. The difficulties encountered in a chemotherapeutic approach are well documented and seem to be accounted for by the fibrosis which occurs between areas of purulence. 3 As pointed out by Baron and Arduino, it is important to realize that primary renal actinomycosis is a misnomer. 4 Actinomyces israeli, the causative agent, enters the body elsewhere and, despite lack of evidence of other involvement, it is believed that a subclinical infection must have existed prior to the renal involvement even though the primary site has healed. Entry through the oral route is most common and, interestingly, the micro-organism lives as a harmless saprophyte in the mouth, tonsils and intestinal tract of normal human subjects. 5 Extension from the primary site occurs by direct spread to tissue, adjacent organs and fascial planes. The lymphatic system is considered immune and any enlargement of nodes usually represents secondary bacterial infection. Rarely, hematogenous spread can occur and, under such circumstances, no organ is immune. Accepted for publication February 3, 1969. Supported by the Ralph ~- Jo~nson Fund, Division of Urology, Baylor Umversity College of Medicine, Houston, Texas. 1 Whisenand, J. M. and Moore, E. V.: Renal actinomycosis, with report of a primary case. . Calif. Med., 74: 133, 1951. 2 Willson-Pepper, J. K.: Report on renal actmomycosis. Brit. J. Urol., 23: 160, 1951. 3 Peabody, J. W., Jr. _and Sea~ury, J. H.: Actinomycosis and nocard10sis. A review of basic differences in therapy. Amer. J. Med., 28: 99, 1960. 4 Baron, E. and Arduino, L. J.: Primary renal . actinomycosis. J. Urol. 1 62: 410, 1949.. 5 Cecil, H. L. and Hill, J. H.: Actmomycosis of the urinary organs. J.A.M.A., 78: 575, 1922. 126
A case is herein reported because of the rarity of the lesion and the difficulty in distinguishing this disease from a neoplasm, even at the operating table. CASE REPORT
A 44-year-old man had a 2-month history of pain in the right flank and right upper quadrant. The patient had lost 40 pounds in the preceding 3 months and had been anorexic. He had not had hematuria or past history of urinary tract symptoms but had experienced night sweats for approximately 3 to 4 weeks. He was seen at another hospital 1 week prior to our examination and results of an upper gastrointestinal series and barium enema had been unremarkable. Abdominal examination revealed guarding in the right upper quadrant and suggestion of a right flank mass. The liver was percussible 4 fingerbreadths below the right costal margin. The midstream urine contained 15 to 20 white cells but only a rare bacillus. An excretory urogram (IVP) revealed a space-occupying mass in the lateral aspect of the grossly enlarged right kidney (fig. 1, A). The admitting hematocrit and hemoglobin were 34 per cent and 10.7 gm. per cent respectively. The white count was 12,800 and showed a shift to the left. Urinalysis revealed 15 to 20 white cells with a rare bacillus seen on a stain of the sediment. Serum sodium was 127 meq. per L, carbon dioxide 25 meq. per L, chloride 88 meq. per L and potassium 5.1 meq. per L. Lactic dehydrogenase, serum glutamic pyruvic transaminase, blood urea nitrogen, fasting blood sugar, serum glutamic oxaloacetic transaminase, calcium, phosphorus, amylase and bilirubin determinations were normal. The bromsulphalein revealed 30 per cent retention in 30 minutes, alkaline phosphatase 19.5 Bessey-Lowry units, prothrombin time 18.1 seconds (control 12.6 seconds). Total protein was 7.6 gm. and albumin was 2.7 gm. Liver scan revealed no intrinsic defect. Barium enema and upper gastrointestinal series were normal. Chest x-ray and bone scan were also normal. A right renal scan revealed a
PRIMARY UNILATERAL RENAL ACTINOJiYCOSIS
127
Fm. l. A, IYP reveals enlarged right kidney and poorly visualized middle pole calyx. B, preoperative retrograde pyelogram reveals compression of middle pole calyx, suggestive of space-occupying mass. C, lateral retrograde pyelogrnm reveals anterior displacement and compression of kidney.
FrG. 2. A, a,·terial phase of selective arteriogram reveals decreased vascularity in area of mass and absence of sharp delineation of lateral border of kidney. B, venous phase of selective renal arteriograrn agarn reveals decreased vascularity and absence of puddling in area of mass.
kidney which measured 19 cm. in length with a large, l.5 cm. in diameter, circular area of decreased A cliagnosi:, of abscess or neoplasm was given
careful consideration because of the febrile course and flank tenderness. The patient was started 011 500 mg. arnpicillin omlly every 6 hour:,. A dramatic ly~is of fernr and improvement
in the clinical situation 1rns noted within 4 The right upper quadrant and right flank tendefness decreased wch that the liver could be pated 4 fingerbreadths belo'A· the costal margin. The right kidney was non-tender. Further evaluation included nepbrotomograms, retropyelogrnms with oblique and lateral views (fig. l, B and C) and selective renal
128
ANHALT AND SCOTT
(fig. 2). During the evaluation course the patient continued to improve. A repeat IVP revealed no change in the renal mass after 3 weeks of ampicillin. The patient had been afebrile for 3 weeks and was asymptomatic and the alkaline phosphatase, prothrombin time and bromsulphalein test had returned to normal. An IVP still suggested a space-occupying mass of the right kidney and, because neoplasm could not be excluded, renal exploration was recommended. The patient was explored transabdominally. The renal vessels were secured prior to manipulating the kidney. On entering the right retroperitoneal space, a large, solid mass was seen occupying most of the right kidney, and the kidney was adherent to the right lobe of the liver, diaphragm and right lateral abdominal wall. The kidney was dissected free with difficulty and a right nephrectomy was done. Frozen sections from the liver and some obvious areas of reaction around the kidney, abdominal wall and diaphragm revealed only chronic inflammatory reaction. It was our impression that this lesion probably represented some variant of a malignant tumor (fig. 3). There was no evidence of purulence in the kidney. Convalescence was uneventful. Ampicillin chemotherapy was continued. The pathological specimen showed typical sulfa granules and a diagnosis of actinomycosis of the kidney was made. The patient was given an extended course
of ampicillin and was discharged to remain on this drug for 6 weeks. He was seen at 3 weeks, 6 weeks, 6 months and 1 year and was doing well clinically on ~>1ch occasion. DISCUSSION
Our patient with actinomycosis had a solitary lesion of the right kidney and spiking fever and chills. Actinomycosis has been reported to occur in many aberrant locations following penetration of oral mucosa, and perforation of ulcers, diverticula and appendices. It has even been reported in the large bowel, small bowel and stomach. :Most cases involve the cervicofacial area (the incidence in this area is commonly as high as 63 per cent). Thoracic actinomycosis accounts for 13 to 15 per cent of cases. 6 Actinomycosis has been described in a variety of forms which vary from typical sulfa granules with purulent string-like lesions to solid masses with multiple foci of purulent, putrid-smelling fistulas and abscesses. Diagnosis is usually made from culture and smears 4 to 6 weeks postoperatively when the wound breaks down and typical sulfa granules begin draining from the wound site. 7 Clinically, patients with actinomycosis usually have fever, although in the early stages of the disease they may be afebrile. As in our case, anemia and leukocytosis can occur. Lymphadenopathy usually is not present. The disease, usually chronic, can be acute as well. Actinomycosis can be progressive with metastatic lesions, cachexia and even death. 8 • 9 Generally, penicillin is regarded as the drug of choice. However, there are reports of successful treatment with isoniazid preparations, streptomycin, sulfa, thymol, aureomycin, potassium iodide and irradiation. There is no previous report of the use of ampicillin in this disease. We believe that the combination of ampicillin and an operation in our case led to the successful outcome. Also, because of the chronic inflammatory response with scarring and decreased vascularization around the actinomycotic process, we can appreciate the possibility that larger doses of 8 Macoul, K. and Souliotis, P. T.: Actinomycosis: solitary nodule. Postgrad. Med., 42: 288, 1967. 7 Hertz, J.: Actinomycosis. Oral, facial and maxillary manifestations. J. Inter. Coll. Surg., 28:
539, 1957. FIG. 3. Gross surgical specimen reveals rock hard, yellow, non-purulent mass filling middle of kidney with normal parenchyma at each end of kidney.
.
.
.
Duncan, J. A.: Abdommal actmomycos1s: changed concepts? Amer. J. Surg., 110: 148, 1965. 9 Pheils, M. T., Reid, D. J. and Ross, C. F.: Abdominal actinomycosis. Brit. J. Surg., 51: 345, 8
1964.
PRHfARY UNILATERAL RENAL ACTINOMYCOSIS
ampicillin may be indicated if actinomycosis is su~pected. t 0 , 11 SUMMARY
\Ye herein desc:ribe an unusual case of 11ctino1,hieh to be 11n to Salmou. H. B. and Koehler J> R.: Angiographv a.11d tena1 nerirenal ·, of thncP,?HS8S, }bdiology, 88:,9,
~vane_,
, , rnc1:ral act11101nycos1s, R,eport on 6
129
abscess or renal tumor. Since differentiation could not be made at the operation nephrectomy was carried out. The pathological diagnosis was actinomycosis. The patient was ~uccessfully treated with ampicillin and is doing well clinically at l year. l'\o report wa;; [onncl in our review of the literature the use of m C8.S8S
with
n1ent. Acta
reference t,o ,tttreomyci 1, near Rcand., 131: 160, lOGCi.,
THE JOURNAL OF UROLOGY
Copyright © 1970 by The Williams & Wilkins Co.
PRINIARY UNILATERAL RENAL ACTINOiVIYCOSIS: CASE REPORT MELVYN ANHALT
AND
RUSSELL SCOTT, JR.
From the Cora ancl Webb Macling Division of Urology, Department of Surgery, Baylor University Colleg~ of Medicine, Houston, Texas
The first case of solitary renal actinomycosis was described in 1878. Whisenand and Moore reviewed the literature in 1951 and reported the sixteenth case of primary renal actinomycosis.1 Willson-Pepper reviewed the literature and stated that primary actinomycosis occurs in 3 forms: I) chronic suppurative lesions resembling a carbuncle, 2) pyelonephritis and 3) pyonephrosis. 2 Reported cases have shown that there is a great propensity toward abscess and sinus tract formation. The difficulties encountered in a chemotherapeutic approach are well documented and seem to be accounted for by the fibrosis which occurs between areas of purulence. 3 As pointed out by Baron and Arduino, it is important to realize that primary renal actinomycosis is a misnomer. 4 Actinomyces israeli, the causative agent, enters the body elsewhere and, despite lack of evidence of other involvement, it is believed that a subclinical infection must have existed prior to the renal involvement even though the primary site has healed. Entry through the oral route is most common and, interestingly, the micro-organism lives as a harmless saprophyte in the mouth, tonsils and intestinal tract of normal human subjects. 5 Extension from the primary site occurs by direct spread to tissue, adjacent organs and fascial planes. The lymphatic system is considered immune and any enlargement of nodes usually represents secondary bacterial infection. Rarely, hematogenous spread can occur and, under such circumstances, no organ is immune. Accepted for publication February 3, 1969. Supported by the Ralph ~- Jo~nson Fund, Division of Urology, Baylor Umversity College of Medicine, Houston, Texas. 1 Whisenand, J. M. and Moore, E. V.: Renal actinomycosis, with report of a primary case. . Calif. Med., 74: 133, 1951. 2 Willson-Pepper, J. K.: Report on renal actmomycosis. Brit. J. Urol., 23: 160, 1951. 3 Peabody, J. W., Jr. _and Sea~ury, J. H.: Actinomycosis and nocard10sis. A review of basic differences in therapy. Amer. J. Med., 28: 99, 1960. 4 Baron, E. and Arduino, L. J.: Primary renal . actinomycosis. J. Urol. 1 62: 410, 1949.. 5 Cecil, H. L. and Hill, J. H.: Actmomycosis of the urinary organs. J.A.M.A., 78: 575, 1922. 126
A case is herein reported because of the rarity of the lesion and the difficulty in distinguishing this disease from a neoplasm, even at the operating table. CASE REPORT
A 44-year-old man had a 2-month history of pain in the right flank and right upper quadrant. The patient had lost 40 pounds in the preceding 3 months and had been anorexic. He had not had hematuria or past history of urinary tract symptoms but had experienced night sweats for approximately 3 to 4 weeks. He was seen at another hospital 1 week prior to our examination and results of an upper gastrointestinal series and barium enema had been unremarkable. Abdominal examination revealed guarding in the right upper quadrant and suggestion of a right flank mass. The liver was percussible 4 fingerbreadths below the right costal margin. The midstream urine contained 15 to 20 white cells but only a rare bacillus. An excretory urogram (IVP) revealed a space-occupying mass in the lateral aspect of the grossly enlarged right kidney (fig. 1, A). The admitting hematocrit and hemoglobin were 34 per cent and 10.7 gm. per cent respectively. The white count was 12,800 and showed a shift to the left. Urinalysis revealed 15 to 20 white cells with a rare bacillus seen on a stain of the sediment. Serum sodium was 127 meq. per L, carbon dioxide 25 meq. per L, chloride 88 meq. per L and potassium 5.1 meq. per L. Lactic dehydrogenase, serum glutamic pyruvic transaminase, blood urea nitrogen, fasting blood sugar, serum glutamic oxaloacetic transaminase, calcium, phosphorus, amylase and bilirubin determinations were normal. The bromsulphalein revealed 30 per cent retention in 30 minutes, alkaline phosphatase 19.5 Bessey-Lowry units, prothrombin time 18.1 seconds (control 12.6 seconds). Total protein was 7.6 gm. and albumin was 2.7 gm. Liver scan revealed no intrinsic defect. Barium enema and upper gastrointestinal series were normal. Chest x-ray and bone scan were also normal. A right renal scan revealed a
PRIMARY UNILATERAL RENAL ACTINOJiYCOSIS
127
Fm. l. A, IYP reveals enlarged right kidney and poorly visualized middle pole calyx. B, preoperative retrograde pyelogram reveals compression of middle pole calyx, suggestive of space-occupying mass. C, lateral retrograde pyelogrnm reveals anterior displacement and compression of kidney.
FrG. 2. A, a,·terial phase of selective arteriogram reveals decreased vascularity in area of mass and absence of sharp delineation of lateral border of kidney. B, venous phase of selective renal arteriograrn agarn reveals decreased vascularity and absence of puddling in area of mass.
kidney which measured 19 cm. in length with a large, l.5 cm. in diameter, circular area of decreased A cliagnosi:, of abscess or neoplasm was given
careful consideration because of the febrile course and flank tenderness. The patient was started 011 500 mg. arnpicillin omlly every 6 hour:,. A dramatic ly~is of fernr and improvement
in the clinical situation 1rns noted within 4 The right upper quadrant and right flank tendefness decreased wch that the liver could be pated 4 fingerbreadths belo'A· the costal margin. The right kidney was non-tender. Further evaluation included nepbrotomograms, retropyelogrnms with oblique and lateral views (fig. l, B and C) and selective renal
128
ANHALT AND SCOTT
(fig. 2). During the evaluation course the patient continued to improve. A repeat IVP revealed no change in the renal mass after 3 weeks of ampicillin. The patient had been afebrile for 3 weeks and was asymptomatic and the alkaline phosphatase, prothrombin time and bromsulphalein test had returned to normal. An IVP still suggested a space-occupying mass of the right kidney and, because neoplasm could not be excluded, renal exploration was recommended. The patient was explored transabdominally. The renal vessels were secured prior to manipulating the kidney. On entering the right retroperitoneal space, a large, solid mass was seen occupying most of the right kidney, and the kidney was adherent to the right lobe of the liver, diaphragm and right lateral abdominal wall. The kidney was dissected free with difficulty and a right nephrectomy was done. Frozen sections from the liver and some obvious areas of reaction around the kidney, abdominal wall and diaphragm revealed only chronic inflammatory reaction. It was our impression that this lesion probably represented some variant of a malignant tumor (fig. 3). There was no evidence of purulence in the kidney. Convalescence was uneventful. Ampicillin chemotherapy was continued. The pathological specimen showed typical sulfa granules and a diagnosis of actinomycosis of the kidney was made. The patient was given an extended course
of ampicillin and was discharged to remain on this drug for 6 weeks. He was seen at 3 weeks, 6 weeks, 6 months and 1 year and was doing well clinically on ~>1ch occasion. DISCUSSION
Our patient with actinomycosis had a solitary lesion of the right kidney and spiking fever and chills. Actinomycosis has been reported to occur in many aberrant locations following penetration of oral mucosa, and perforation of ulcers, diverticula and appendices. It has even been reported in the large bowel, small bowel and stomach. :Most cases involve the cervicofacial area (the incidence in this area is commonly as high as 63 per cent). Thoracic actinomycosis accounts for 13 to 15 per cent of cases. 6 Actinomycosis has been described in a variety of forms which vary from typical sulfa granules with purulent string-like lesions to solid masses with multiple foci of purulent, putrid-smelling fistulas and abscesses. Diagnosis is usually made from culture and smears 4 to 6 weeks postoperatively when the wound breaks down and typical sulfa granules begin draining from the wound site. 7 Clinically, patients with actinomycosis usually have fever, although in the early stages of the disease they may be afebrile. As in our case, anemia and leukocytosis can occur. Lymphadenopathy usually is not present. The disease, usually chronic, can be acute as well. Actinomycosis can be progressive with metastatic lesions, cachexia and even death. 8 • 9 Generally, penicillin is regarded as the drug of choice. However, there are reports of successful treatment with isoniazid preparations, streptomycin, sulfa, thymol, aureomycin, potassium iodide and irradiation. There is no previous report of the use of ampicillin in this disease. We believe that the combination of ampicillin and an operation in our case led to the successful outcome. Also, because of the chronic inflammatory response with scarring and decreased vascularization around the actinomycotic process, we can appreciate the possibility that larger doses of 8 Macoul, K. and Souliotis, P. T.: Actinomycosis: solitary nodule. Postgrad. Med., 42: 288, 1967. 7 Hertz, J.: Actinomycosis. Oral, facial and maxillary manifestations. J. Inter. Coll. Surg., 28:
539, 1957. FIG. 3. Gross surgical specimen reveals rock hard, yellow, non-purulent mass filling middle of kidney with normal parenchyma at each end of kidney.
.
.
.
Duncan, J. A.: Abdommal actmomycos1s: changed concepts? Amer. J. Surg., 110: 148, 1965. 9 Pheils, M. T., Reid, D. J. and Ross, C. F.: Abdominal actinomycosis. Brit. J. Surg., 51: 345, 8
1964.
PRHfARY UNILATERAL RENAL ACTINOMYCOSIS
ampicillin may be indicated if actinomycosis is su~pected. t 0 , 11 SUMMARY
\Ye herein desc:ribe an unusual case of 11ctino1,hieh to be 11n to Salmou. H. B. and Koehler J> R.: Angiographv a.11d tena1 nerirenal ·, of thncP,?HS8S, }bdiology, 88:,9,
~vane_,
, , rnc1:ral act11101nycos1s, R,eport on 6
129
abscess or renal tumor. Since differentiation could not be made at the operation nephrectomy was carried out. The pathological diagnosis was actinomycosis. The patient was ~uccessfully treated with ampicillin and is doing well clinically at l year. l'\o report wa;; [onncl in our review of the literature the use of m C8.S8S
with
n1ent. Acta
reference t,o ,tttreomyci 1, near Rcand., 131: 160, lOGCi.,