Complex bilateral methicillin-resistant Staphylococcus aureus renal and perirenal abscesses: a...
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BJU International (1999), 83, 863–864 CASE REPORT Complex bilateral methicillin-resistant Staphylococcus aureus renal and perirenal abscesses: a multidisciplinary approach and the use of C-reactive protein as an aid to management L.A. LILAS, F.H. MUMTAZ, A.A. MACDONALD andD.C. HANBURY Lister Hospital, Stevenage, UK Case report A 50-year-old diabetic man, using CISC for a nonre- fluxing atonic bladder, presented with a history of recur- rent UTI, fever and right loin pain. Initial investigations showed an epidemic methicillin-resistant Staphylococcus aureus (EMRSA)-15 UTI and bacteraemia. Upper tract imaging, ultrasonography (US) and CT suggested a right upper-pole intrarenal abscess. After apparent successful conservative treatment (intravenous teicoplanin/oral tri- methoprim), he re-presented 2 months later with fever, rigors and bilateral loin pain. Initial urine culture was sterile but blood cultures grew EMRSA-15. Both US and CT (Fig. 1a) identified bilateral multiple intrarenal and a right-sided perirenal abscesses. Staged treatments over a 6-week period included initial intravenous antibiotics, percutaneous aspiration (left kidney) and open surgical drainage (right kidney). The progress of each treatment was evaluated with repeat CT and US, together with serial measurement of C-reactive protein (CRP) (Fig. 2). Despite a salt-losing nephropathy, chronic anaemia and long-term isolation on the ward, the patient made a slow but steady recovery. Follow-up CT performed 4 weeks after discharge (Fig. 1b) showed complete reso- lution of the abscesses, although the patient still required mineralocorticoid supplementation for his salt-losing b a nephropathy. Teicoplanin was continued for a further Fig. 1. CT scans a, before intervention, showing multiple bilateral 12 weeks until his CRP levels had normalised; he intrarenal and perirenal (right side) abscesses, and b, 4 weeks after continues on oral trimethoprim. discharge, showing complete resolution with good preservation of the renal parenchyma. Comment Multiple bilateral renal abscesses in the post-antibiotic increase in renal infections. It is therefore important that urologists be vigilant in preventing, detecting and treat- era are an uncommon entity [1] and their management can be challenging. Although staphylococci are now ing MRSA. A multidisciplinary approach to the MRSA organism believed to cause 8% [2] of renal abscesses, in the pre- antibiotic era they caused most renal abscesses [2]. The was used successfully in this case. As advocated by others [4], we used CRP at all stages (i.e. diagnosis, management of multiple suppurative renal infections caused by MRSA have not been reported. In light of the treatment and follow-up) as part of the management plan. Despite the apparent clinical, microbiological and well-documented [3] increase in the incidence and preva- lence of MRSA, the possibility exists for a concomitant radiological resolution of the abscesses, CRP levels 863 © 1999 BJU International
Transcript of Complex bilateral methicillin-resistant Staphylococcus aureus renal and perirenal abscesses: a...
BJU International (1999), 83, 863–864
CASE RE PORT
Complex bilateral methicillin-resistant Staphylococcus aureusrenal and perirenal abscesses: a multidisciplinary approachand the use of C-reactive protein as an aid to managementL.A. L ILAS, F .H. MUMTAZ, A.A. MACDONALD and D.C. HANBURYLister Hospital, Stevenage, UK
Case report
A 50-year-old diabetic man, using CISC for a nonre-fluxing atonic bladder, presented with a history of recur-rent UTI, fever and right loin pain. Initial investigationsshowed an epidemic methicillin-resistant Staphylococcusaureus (EMRSA)-15 UTI and bacteraemia. Upper tractimaging, ultrasonography (US) and CT suggested a rightupper-pole intrarenal abscess. After apparent successfulconservative treatment (intravenous teicoplanin/oral tri-methoprim), he re-presented 2 months later with fever,rigors and bilateral loin pain. Initial urine culture wassterile but blood cultures grew EMRSA-15. Both US andCT (Fig. 1a) identified bilateral multiple intrarenal and aright-sided perirenal abscesses. Staged treatments over a6-week period included initial intravenous antibiotics,percutaneous aspiration (left kidney) and open surgicaldrainage (right kidney). The progress of each treatmentwas evaluated with repeat CT and US, together withserial measurement of C-reactive protein (CRP) (Fig. 2).Despite a salt-losing nephropathy, chronic anaemia andlong-term isolation on the ward, the patient made aslow but steady recovery. Follow-up CT performed 4weeks after discharge (Fig. 1b) showed complete reso-lution of the abscesses, although the patient still requiredmineralocorticoid supplementation for his salt-losing b
a
nephropathy. Teicoplanin was continued for a furtherFig. 1. CT scans a, before intervention, showing multiple bilateral12 weeks until his CRP levels had normalised; heintrarenal and perirenal (right side) abscesses, and b, 4 weeks aftercontinues on oral trimethoprim.discharge, showing complete resolution with good preservation ofthe renal parenchyma.
Comment
Multiple bilateral renal abscesses in the post-antibiotic increase in renal infections. It is therefore important thaturologists be vigilant in preventing, detecting and treat-era are an uncommon entity [1] and their management
can be challenging. Although staphylococci are now ing MRSA.A multidisciplinary approach to the MRSA organismbelieved to cause 8% [2] of renal abscesses, in the pre-
antibiotic era they caused most renal abscesses [2]. The was used successfully in this case. As advocated byothers [4], we used CRP at all stages (i.e. diagnosis,management of multiple suppurative renal infections
caused by MRSA have not been reported. In light of the treatment and follow-up) as part of the managementplan. Despite the apparent clinical, microbiological andwell-documented [3] increase in the incidence and preva-
lence of MRSA, the possibility exists for a concomitant radiological resolution of the abscesses, CRP levels
863© 1999 BJU International
864 CASE REPORT
lished MRSA renal abscesses, in particular when theseare in the perirenal space [2].
References
1 Chadwick PR, Thomas NB. Conservative management of apatient with bilateral renal abscesses. J Infect 1994; 28: 83–7
2 Fowler JE Jr, Perkins T. Presentation, diagnosis and treatmentof renal abscesses: 1972-1988. J Urol 1994; 151: 847–51
3 Gordon J. Clinical significance of methicillin-sensitive andmethicillin-resistant Staphylococcus aureus in UK hospitalsand relevance of povidone-iodine in their control. PostgradMed J 1993; 69: 106–16
4 Ballous SP, Kushner I. C-Reactive protein and the acutephase response. Adv Intern Med 1992; 37: 313–36
Fig. 2. The change in CRP level with time and response to varioustreatments.
Authors
L.A. Lilas, FRCS, DipUrol, Senior House OBcer.remained elevated, suggesting the possibility of residual
F.H. Mumtaz, FRCS, Specialist Registrar.MRSA infection. Thus it was felt necessary to continue A.A. MacDonald, MBChB, MSc, MRCPath, Consultantwith antibiotic treatment to prevent another relapse. Microbiologist.Although more conservative approaches have been D.C. Hanbury, MS, FRCS(Urol), Consultant Urological Surgeon.advocated [1], this case exemplifies the inadequacy of Correspondence: Dr L.A. Lilas, Lister Hospital, Coreys Mill Lane,
Stevenage SG1 4AB, UK.antibiotic monotherapy in the management of estab-
© 1999 BJU International 83, 863–864
