Mary Thorndike Gillian Lieberman, MD

August 2001

Acute Renal Infections

Mary Thorndike Harvard Medical School Year III Gillian Lieberman, MD

Mary Thorndike Gillian Lieberman, MD

Acute bacterial pyelonephritis Renal Abscess Emphysematous Pyelonephritis Pyohydronephrosis Xanthogranulomatous Pyelonephritis

Mary Thorndike Gillian Lieberman, MD

Acute Bacterial Pyelonephritis

Infection of collecting system and parenchyma

Ascending: Escherichia coli Hematogenous: Staphylococcus aureus Flank pain and fever

Usually a clinical diagnosis

Mary Thorndike Gillian Lieberman, MD

Imaging of Acute Pyelonephritis: Indications

Diagnostic uncertainty Very ill patients Persistent symptoms despite treatment Recurrent renal infection

Mary Thorndike Gillian Lieberman, MD

Imaging of Acute Pyelonephritis: Modalities

Intravenous Urography Ultrasound Computed Tomography (CT Scan) Nuclear Scanning
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Mary Thorndike Gillian Lieberman, MD

Intravenous Urography
X-ray with IV contrast Historically method of choice Not very sensitive Normal in 75% of pyelonephritis cases

No longer used in most situations

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Mary Thorndike Gillian Lieberman, MD

Ultrasonography
Lower sensitivity than CT or nuclear scans Modality of choice in pregnant women Positive Findings: Enlargement of entire kidney Hypoechoic cortex: edema Focal hyperechoic areas: early abcess
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Mary Thorndike Gillian Lieberman, MD

Sonogram: Acute Pyelonephritis

Hypoechoic kidney with perinephric extension

Radiology Clinics of North America 34:5, p.968

Mary Thorndike Gillian Lieberman, MD

CT Scanning
Sensitive and accurate Demonstrates Anatomic changes Demonstrates Functional deficits

Modality of choice in most patients

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Mary Thorndike Gillian Lieberman, MD

Non-Contrast CT
Film Findings Focal swelling Irregularity of calyces Perinephric fat stranding Thickening of Gerotas Fascia
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Mary Thorndike Gillian Lieberman, MD

Non-Contrast CT: Pyelonephritis

Enlarged right kidney

BIDMC PACS System

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Mary Thorndike Gillian Lieberman, MD

CT with Contrast: Nephrogenic Phase

Film Findings: Cortical perfusion defects:
Areas of decreased attenuation Often wedge-shaped May indicate early abcess formation Striated nephrogram
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Mary Thorndike Gillian Lieberman, MD

Contrast CT: Pyelonephritis

Focal perfusion deficit

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BIDMC PACS System

Mary Thorndike Gillian Lieberman, MD

Contrast CT: Pyelonephritis

Focal perfusion deficits

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BIDMS PACS System

Mary Thorndike Gillian Lieberman, MD

Contrast CT: Pyelonephritis

Focal perfusion deficits

Courtesy of Michelle Swire, MD

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Mary Thorndike Gillian Lieberman, MD

Contrast CT: Pyelonephritis

Focal perfusion deficit

Renal cyst

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BIDMC PACS System

Mary Thorndike Gillian Lieberman, MD

Contrast CT: Pyelonephritis

Focal perfusion deficit Fat stranding and fascial thickening

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BIDMC PACS System

Mary Thorndike Gillian Lieberman, MD

Contrast CT: Pyelonephritis

Focal perfusion deficits

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BIDMC PACS System

Mary Thorndike Gillian Lieberman, MD

Coronal Reconstruction
Focal perfusion deficit

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BIDMC PACS System

Mary Thorndike Gillian Lieberman, MD

Differential Diagnosis for Perfusion Deficits on CT

Acute pyelonephritis Infarct Emboli Lymphoma
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Mary Thorndike Gillian Lieberman, MD

Differential Diagnosis for Striated Nephrogram

Acute pyelonephritis Acute obstruction Renal vein thrombosis Infantile polycystic disease Medullary sponge kidney
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Radiology Recall

Mary Thorndike Gillian Lieberman, MD

Radionuclide Imaging
Infection-seeking agents
Gallium citrate (GA-67) Indium-111-labeled white blood cells (IN-111WBC)

Concentrate within areas of inflammation which are hot spots Can localize occult sites of infection Alternative to CT

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Mary Thorndike Gillian Lieberman, MD

Radionuclide Imaging
Kidney-seeking agents
Technetium Tc-99m glucoheptonate (Tc-99m GH) Technetium Tc-99m dimercaptosuccinic acid (Tc-99m DMSA)

Concentrate in renal cortex, area of infection is therefore a cold spot Children: most sensitive modality Adults: functional studies post-infection

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Mary Thorndike Gillian Lieberman, MD

TC-99m-DMSA Scan (Kidney Seeking)

Cortical Loss

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Radiologic Clinics of North America 34:5 p. 974

Mary Thorndike Gillian Lieberman, MD

Renal Abscess

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BIDMC Film Library

Mary Thorndike Gillian Lieberman, MD

Emphysematous Pyelonephritis

Gas in kidney

http://www.bbmcradiology.org/CasesoftheMonth/Casejan99/COM2dec98.home.html

Life-threatening Infection in Diabetic Patients

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Mary Thorndike Gillian Lieberman, MD

Pyohydronephrosis
Infection of obstructed kidney CT with contrast is modality of choice Radiologic presentation:
Pyelonephritis Obstruction
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Mary Thorndike Gillian Lieberman, MD

Xanthogranulomatous Pyelonephritis

www.eurorad.org

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Mary Thorndike Gillian Lieberman, MD

Review of imaging recommendations for renal infection

Modality of Choice: CT with IV Contrast Findings: Focal Perfusion Deficits Pregnant women: Ultrasound Children: Radionuclide scans
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Mary Thorndike Gillian Lieberman, MD

References
Gay, Spencer, and Richard J. Woodcock, Jr. Radiology Recall (2000). Philadelphia: Lippincott Williams & Wilkins.

Langer, Jill E. Computed Tomography and Ultasonography of Acute Renal Abnormalities. Seminars in Roentgenology 36:2 (2001), pp.99-107.

Papanicolaou, Nicholas, and Richard C. Pfister. Acute Renal Infections. Radiologic Clinics of North America 34:5 (1996), 30 pp.965-995.

Mary Thorndike Gillian Lieberman, MD

Acknowledgements
Daniel Saurborn, MD Michelle Nebres Swire, MD Aradhana Venkatesan, MD Gillian Lieberman, MD Pamela Lepkowski Larry Barberas and Cara Lyn Damour
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