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Renal Carbuncle: Antibiotic Therapy Governed by Ultrasonically Guided Aspiration
Vol. 109, May
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1973 by The Williams & Wilkins Co.
RENAL CARBUNCLE: ANTIBIOTIC THERAPY GOVERNED BY ULTRASONICALLY GUIDED ASPIRATION J. FOG PEDERSEN, S. HANCKE
AND
J. KVIST KRISTENSEN
From the Ultrasonic Laboratory, Department of Surgery H, Gentofte Hospital, Hellerup, Denmark
Lyons and associates recently reported the fourth case of a renal carbuncle treated only with antibiotics. 1 Diagnosis was based on the clinical examination and on a renal arteriogram. The patient was given oxacillin with good clinical effect and an arteriogram was normal 3 months later. In 1970 Voegeli presented a series of 7 renal carbuncles diagnosed by renal arteriography, 3 of which were treated only by antibiotics. 2 In one of these cases aspiration revealed cultures of Escherichia coli and thus provided a possible basis for adequate treatment, although this is not stated. Herein is described another case of a renal carbuncle successfully treated with antibiotics. Bacteriologic diagnosis was achieved prior to treatment through aspiration from the abscess under the guidance of ultrasound. PRINCIPLE OF ULTRASONICALLY GUIDED PERCUTANEOUS PUNCTURE
A routine procedure for ultrasonic scanning of the kidneys has been reported recently. 3 Transverse and longitudinal 2-dimensional sectional pictures are produced at intervals of 1 cm. Thereby space-occupying lesions 2 cm. or more can be demonstrated. Percutaneous puncture of renal masses can be performed advantageously under the guidance of ultrasound. 4 The lesion to be punctured is outlined in an optimum section using a transducer which is perforated by a central canal. The direction for puncture is established from this picture and the distance from the skin to the puncture target is marked off on the needle. The needle is then introduced through the puncture transducer up to the mark while the correct direction is observed on the oscilloscopic screen. The equipment used is a modified Hewlett Packard 7214A diagnostic sounder, an Escoline B-scanner and a modified Tektronix 564 storage Accepted for publication September 29, 1972. 1 Lyons, R. W., Long, J.M., Lytton, B. and Andriole, V. T.: Arteriography and antibiotic therapy of a renal carbuncle. J. Urol., 107: 524, 1972. 2 Voegeli, E.: Diagnose von Abscessen im Bereich der Nieren durch renale Angiographie und direkte Punktion. Radiologe, 10: 87, 1970. 'Kristensen, J. K., Gammelgaard, P.A., Holm, H. H. and Rasmussen, S. N.: Ultrasound in the demonstration of renal masses. Brit. J. Urol., 44: 517, 1972. • Kristensen, J. K., Holm, H. H., Rasmussen, S. N. and Barlebo, H.: Ultrasonically guided percutaneous puncture of renal masses. Scand. J. Urol. Nephrol., suppl. 15, 6: 49, 1972.
oscilloscope. A 2.25 MHz transducer is used, focused at a distance of 10 cm. CASE REPORT
H. D., H 2103/71-72, a 66-year-old man, was admitted to the hospital for acute urinary retention. The patient was febrile and moderately tender in both kidney regions. A distended bladder was demonstrated and a urethral catheter was introduced. Cultures from the urine showed no significant growth. An excretory urogram (IVP) 1 month before admission to the hospital showed a stone in a distal calix of the right kidney, 2 bladder stones and residual urine. The case was considered to be one of urinary tract infection in a patient with urinary retention owing to an enlarged prostate. The patient was routinely given penicillin and streptomycin but these had no effect on the elevated temperature. Ultrasonic scanning demonstrated a 5 cm. large, rather homogenous mass in the upper pole of the left kidney, thought to be either an abscess or a solid tumor (part A of figure). At ultrasonically guided fine-needle aspiration, thick yellow pus was obtained, indicating an abscess. Cultures showed growth of Klebsiella, sensitive to sulfonamides and polymyxins. Therefore, sulfamethizole and colymycin were administered. An IVP showed compression of the left pelvis corresponding to the ultrasound findings. To eliminate possible underlying malignancy, selective renal arteriography was done, showing some displacement of the vessels corresponding to the abscess but no signs of neoplasia. The patient improved, the initially elevated sedimentation rate and white blood count became normal and subsequent ultrasonic scanning of the left kidney showed the abscess diminishing. The patient was discharged from the hospital after 4 weeks. Two weeks later the kidney appeared to be normal on ultrasonic scanning (part B of figure) and the medication was withdrawn. Since that time the patient has undergone transurethral resection and removal of bladder stones without complications. DISCUSSION
Usually renal abscesses are metastatic and caused by staphylococci. The antibiotic of choice in such infections is penicillin. In our case the infecting organism was Klebsiella, which is resistant to penicillin. Therefore, the value of obtain777
778
PEDERSEN, HANCKE AND KRISTENSEN
A, scans before treatment show abscess in upper pole. B, scans after treatment reveal normal kidney. (Cross section above and longitudinal section below.)
ing a specimen for bacteriologic examination is obvious. This is also emphasized by the fact that the patient did not respond to the initial treatment of penicillin and streptomycin. It is not possible to differentiate between an abscess and a solid mass on the ultrasonic picture. However, when 1) arteriography shows no signs of neoplasia, 2) aspiration provides a bacteriological diagnosis and 3) appropriate antibiotic therapy is followed by a prompt response in clinical, laboratory and ultrasonic findings, the mass can be
considered an abscess. In such cases there is no need for repeat arteriography. SUMMARY
A renal carbuncle was punctured under the guidance of ultrasound. Cultures showed Klebsiella to be the infecting organism and appropriate antibiotic therapy was started. On repeat ultrasonic examinations the carbuncle was no longer present.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1973 by The Williams & Wilkins Co.
RENAL CARBUNCLE: ANTIBIOTIC THERAPY GOVERNED BY ULTRASONICALLY GUIDED ASPIRATION J. FOG PEDERSEN, S. HANCKE
AND
J. KVIST KRISTENSEN
From the Ultrasonic Laboratory, Department of Surgery H, Gentofte Hospital, Hellerup, Denmark
Lyons and associates recently reported the fourth case of a renal carbuncle treated only with antibiotics. 1 Diagnosis was based on the clinical examination and on a renal arteriogram. The patient was given oxacillin with good clinical effect and an arteriogram was normal 3 months later. In 1970 Voegeli presented a series of 7 renal carbuncles diagnosed by renal arteriography, 3 of which were treated only by antibiotics. 2 In one of these cases aspiration revealed cultures of Escherichia coli and thus provided a possible basis for adequate treatment, although this is not stated. Herein is described another case of a renal carbuncle successfully treated with antibiotics. Bacteriologic diagnosis was achieved prior to treatment through aspiration from the abscess under the guidance of ultrasound. PRINCIPLE OF ULTRASONICALLY GUIDED PERCUTANEOUS PUNCTURE
A routine procedure for ultrasonic scanning of the kidneys has been reported recently. 3 Transverse and longitudinal 2-dimensional sectional pictures are produced at intervals of 1 cm. Thereby space-occupying lesions 2 cm. or more can be demonstrated. Percutaneous puncture of renal masses can be performed advantageously under the guidance of ultrasound. 4 The lesion to be punctured is outlined in an optimum section using a transducer which is perforated by a central canal. The direction for puncture is established from this picture and the distance from the skin to the puncture target is marked off on the needle. The needle is then introduced through the puncture transducer up to the mark while the correct direction is observed on the oscilloscopic screen. The equipment used is a modified Hewlett Packard 7214A diagnostic sounder, an Escoline B-scanner and a modified Tektronix 564 storage Accepted for publication September 29, 1972. 1 Lyons, R. W., Long, J.M., Lytton, B. and Andriole, V. T.: Arteriography and antibiotic therapy of a renal carbuncle. J. Urol., 107: 524, 1972. 2 Voegeli, E.: Diagnose von Abscessen im Bereich der Nieren durch renale Angiographie und direkte Punktion. Radiologe, 10: 87, 1970. 'Kristensen, J. K., Gammelgaard, P.A., Holm, H. H. and Rasmussen, S. N.: Ultrasound in the demonstration of renal masses. Brit. J. Urol., 44: 517, 1972. • Kristensen, J. K., Holm, H. H., Rasmussen, S. N. and Barlebo, H.: Ultrasonically guided percutaneous puncture of renal masses. Scand. J. Urol. Nephrol., suppl. 15, 6: 49, 1972.
oscilloscope. A 2.25 MHz transducer is used, focused at a distance of 10 cm. CASE REPORT
H. D., H 2103/71-72, a 66-year-old man, was admitted to the hospital for acute urinary retention. The patient was febrile and moderately tender in both kidney regions. A distended bladder was demonstrated and a urethral catheter was introduced. Cultures from the urine showed no significant growth. An excretory urogram (IVP) 1 month before admission to the hospital showed a stone in a distal calix of the right kidney, 2 bladder stones and residual urine. The case was considered to be one of urinary tract infection in a patient with urinary retention owing to an enlarged prostate. The patient was routinely given penicillin and streptomycin but these had no effect on the elevated temperature. Ultrasonic scanning demonstrated a 5 cm. large, rather homogenous mass in the upper pole of the left kidney, thought to be either an abscess or a solid tumor (part A of figure). At ultrasonically guided fine-needle aspiration, thick yellow pus was obtained, indicating an abscess. Cultures showed growth of Klebsiella, sensitive to sulfonamides and polymyxins. Therefore, sulfamethizole and colymycin were administered. An IVP showed compression of the left pelvis corresponding to the ultrasound findings. To eliminate possible underlying malignancy, selective renal arteriography was done, showing some displacement of the vessels corresponding to the abscess but no signs of neoplasia. The patient improved, the initially elevated sedimentation rate and white blood count became normal and subsequent ultrasonic scanning of the left kidney showed the abscess diminishing. The patient was discharged from the hospital after 4 weeks. Two weeks later the kidney appeared to be normal on ultrasonic scanning (part B of figure) and the medication was withdrawn. Since that time the patient has undergone transurethral resection and removal of bladder stones without complications. DISCUSSION
Usually renal abscesses are metastatic and caused by staphylococci. The antibiotic of choice in such infections is penicillin. In our case the infecting organism was Klebsiella, which is resistant to penicillin. Therefore, the value of obtain777
778
PEDERSEN, HANCKE AND KRISTENSEN
A, scans before treatment show abscess in upper pole. B, scans after treatment reveal normal kidney. (Cross section above and longitudinal section below.)
ing a specimen for bacteriologic examination is obvious. This is also emphasized by the fact that the patient did not respond to the initial treatment of penicillin and streptomycin. It is not possible to differentiate between an abscess and a solid mass on the ultrasonic picture. However, when 1) arteriography shows no signs of neoplasia, 2) aspiration provides a bacteriological diagnosis and 3) appropriate antibiotic therapy is followed by a prompt response in clinical, laboratory and ultrasonic findings, the mass can be
considered an abscess. In such cases there is no need for repeat arteriography. SUMMARY
A renal carbuncle was punctured under the guidance of ultrasound. Cultures showed Klebsiella to be the infecting organism and appropriate antibiotic therapy was started. On repeat ultrasonic examinations the carbuncle was no longer present.