Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis

ByByShereen Hanafi HassanShereen Hanafi Hassan

OverviewOverview It’s unusual suppurative granulomatous It’s unusual suppurative granulomatous

reaction to chronic renal infection.reaction to chronic renal infection. Often occurs with chronic obstruction from a Often occurs with chronic obstruction from a

calculus, stricture, or a tumor.calculus, stricture, or a tumor. Middle aged females are more common to be Middle aged females are more common to be

affected. A history of recurrent or chronic UTI affected. A history of recurrent or chronic UTI usually present. usually present.

Produces either diffuse (80-90%), or Produces either diffuse (80-90%), or sometimes focal (10-20%), destruction of the sometimes focal (10-20%), destruction of the kidneykidney

Almost always unilateral; may affect either Almost always unilateral; may affect either kidney with equal frequency.kidney with equal frequency.

PathologyPathology

Pathognomonic microscopic feature is lipid-Pathognomonic microscopic feature is lipid-laden, foamy macrophage (xanthoma cells).laden, foamy macrophage (xanthoma cells).

The gross appearance of XGP is a mass The gross appearance of XGP is a mass of yellow tissue with regional necrosis of yellow tissue with regional necrosis and hemorrhage, superficially and hemorrhage, superficially resembling resembling renal cell carcinomarenal cell carcinoma. .

Has tumor-like behavior and can spread to Has tumor-like behavior and can spread to involve and/or destroy adjacent organs.involve and/or destroy adjacent organs.

Clinical PictureClinical Picture

Fever.Fever. Flank pain.Flank pain. Weight loss.Weight loss. Dysuria.Dysuria. Flank mass & tenderness.Flank mass & tenderness.

Laboratory Laboratory InvestigationsInvestigations

CBC CBC may reveal leukocytosis and may reveal leukocytosis and anemiaanemia . .

Urine analysis shows pyuria, Urine analysis shows pyuria, hematuria, and proteinuria. hematuria, and proteinuria.

E-Coli, Proteus species commonly E-Coli, Proteus species commonly appear in C/S of urine of such cases.appear in C/S of urine of such cases.

RadiologyRadiology

The radiological modality of choice is The radiological modality of choice is CT, and it shows:CT, and it shows: Heterogeneous, non-enhancing massHeterogeneous, non-enhancing mass Hydronephrotic kidneyHydronephrotic kidney Destruction of the normal renal Destruction of the normal renal

parenchymaparenchyma Stones, of staghorn size, occur in 80% of Stones, of staghorn size, occur in 80% of

casescases May also demonstrate small calcificationsMay also demonstrate small calcifications

Extrarenal extension.Extrarenal extension.

RadiologyRadiology

On ultrasoundOn ultrasound Enlarged kidney which maintains Enlarged kidney which maintains

reniform shapereniform shape Loss of corticomedullary differentiationLoss of corticomedullary differentiation Multiple hypoechoic abscesses, Multiple hypoechoic abscesses,

granulomas or dilated calycesgranulomas or dilated calyces Loss of renal cortical tissueLoss of renal cortical tissue

RadiologyRadiology

Other radiological modalities:Other radiological modalities:

* Plain X-ray.* Plain X-ray.

* IVU.* IVU.

* MRI.* MRI.

* * MAG-3MAG-3, or , or Tc-DMSA renal Tc-DMSA renal scanning.scanning.

Differential DiagnosisDifferential Diagnosis

Renal cell carcinoma Renal cell carcinoma

Chronic Chronic pyelonephritis.pyelonephritis.

TreatmentTreatment Surgical removal Surgical removal

> Nephrectomy or sometimes partial > Nephrectomy or sometimes partial nephrectomy.nephrectomy.

Antibiotic therapyAntibiotic therapy

> > First-generation cephalosporins and First-generation cephalosporins and trimethoprim-sulfamethoxazole. A broader trimethoprim-sulfamethoxazole. A broader spectrum antibiotic maybe needed in some cases.spectrum antibiotic maybe needed in some cases.

PrognosisPrognosis

The overall prognosis for is The overall prognosis for is good.good.

Death is rare.Death is rare.