Subsequently almost all fragments passed alongside the stent. Partial disintegration was achieved after the second ESWL, larger fragments were treated during the third ESWL under ultrasound guidance. Stone removal was initiated 3 weeks later by inserting a double-J ureteral stent followed by 3 cycles of extracorporeal shock wave lithotripsy (ESWL). b Double J ureteral stent with disintegrated stones after third ESWL. (fig.2a 2a).Ī Further follow-up MDCT shows resolution of abscesses and scarring of the upper pole. Postoperative peritonitis was suspected, but MDCT was unremarkable and showed resolution of XP (fig. She received 10 days of antibiotic cover with amoxicillin/clavulanic acid, which led to an improvement of laboratory values (WBC fell from 19.09 to 7.04 × 10 9/l). CT presented a perforated appendix and an emergency appendectomy was carried out. The patient was readmitted with massive right-sided abdominal pain and guarding. A long-term urinary catheter was never required. Blood count (Hb 10.5 mg/dl) and C-reactive protein (7.0 mg/l) were back in the normal range, the urine was sterile. After 40 days of continuous antibiotic cover only minor abscess residues and declining retroperitoneal lymphadenopathy (25–18 mm) could be demonstrated. The antibiotic therapy was changed to twice daily oral cefuroxime 500 mg. Additionally Proteus mirabilis was grown from the aspirate. Abundant blood and detritus with a degenerative cell picture and no evidence of malignancy were detected in the aspirate. This drain was flushed with 3–5 ml sodium chloride 3 times daily under aseptic conditions, to prevent drainage obstruction and was removed after 7 days. The subhepatic abscess formation appeared consolidated and encapsulated, the renal calculus with a diameter of 2.5 cm in the middle calyx was unchanged.ĬT-guided abscess drainage of the largest fluid collection was carried out introducing a 10F drain and approximately 20 ml of putrid fluid and histological tissue were obtained (fig. After 1 week of parenteral antibiotic therapy (meropenem 500 mg, 3 times daily) repeat MDCT showed slight improvement with a trend towards abscess regression. Recent contrast-enhanced multidetector CT (MDCT) showed a mass in the upper pole of the right kidney with a multi-located abscess and several stones in the renal calyces. b CT-guided abscess drainage was performed in prone position. There is contrast material present in renal pelvis. This case report has been approved by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.Ī MDCT in the coronal plane demonstrates a multiloculated abscess in the upper pole of the right kidney (arrows). We present a complex case of XP with kidney preserving therapy for multiple upper pole abscesses, obstructive nephrolithiasis, and subsequent gangrenous appendicitis followed by enterocolitis. In literature there are many studies which describe a trend towards surgical procedures due to suspected malignancy and kidney preserving therapies are foregone. The yellowish tumor masses hold lipid-containing foam cells (xanthoma cells). Clinical presentation and imaging of XP are difficult to differentiate from renal cell carcinoma therefore the diagnosis is usually made postoperatively/ histologically. Obstructive urolithiasis along the urinary tract and ascending urogenital infections are frequently observed. Xanthogranulomatous pyelonephritis (XP), which accounts for less than 1% of all cases of chronic pyelonephritis, is a rare form of inflammatory/abscess-forming nephropathy and leads to progressive loss of renal function.
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