Kathleen B. Miranda, M.D.

Medical Resident February 5, 2009 1

Objectives



To present a case of perinephric abscess



To discuss the etiology, predisposing factors, complications, and management of perinephric abscess

2

Identifying Data A.A. 52/female Single

3

Chief Complaint Abdominal Enlargement

4

History of Present Illness

3 days PTA

enlarging abdomen with palpable mass over the right flank area vague abdominal pain no fever, dysuria,hematuria no trauma anorexia 5

History of Present Illness

Consult CT scan of the abdomen done revealing presence of right perinephric and pararenal abscess formation Admission 6

Impression 8/7: CT Scan of Whole Abdomen

• Right hydronephrosis with pyelonephritis • Presence of perinephric and pararenal abscess formation noted • Emphysematous cystitis • Ileus • Contracted gallbladder • Atherosclerotic aorta and common iliac arteries 7

Review of Systems

•  Skin: (-) pruritus, (-) rashes, (-) easy bruising, (-) telangestasia, (-) spiderangiomatas HEENT: (-) headache, (-) dizziness, (-) BOV, (-) eye redness, (-) colds, (-) epistaxis, (-) deafness, (-) ear discharge, (-) bleeding gums, (-) oral sores, (-) hoarseness, (-) neck pain, (-) limitation of motion 8

Review of Systems

   Respiratory: (-) cough, (-) DOB, (-) hemoptysis Cardiovascular: (-) chest pain, (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal dyspnea Gastrointestinal: (-) dysphagia, (+) early satiety, (-) jaundice, (-) nausea, (-) vomiting, (-) hematemesis, (+) constipation, (-) diarrhea 9

Review of Systems

   Extremities: (-) joint pains, (-) swelling Neurologic: (-) seizures, (-) tremors, (-) involuntary movement Endocrinologic: (-) polyphagia, (-) polyuria, (-) polydipsia 10

Past Medical History

  Chronic schizophrenia, paranoid type since her college years and maintained on Clozapine (Leponex) and Fluoxetine (Prozac). Diabetes mellitus type 2 since 2000 currently on Glimepiride 2mg (1/2-0-0) prior to admission. Home monitoring of blood sugar at 98-135mg% pre-breakfast. 11

Family History (+) Hypertension- mother (+) Diabetes Mellitus- mother (-) Heart disease, psychiatric disorders, kidney disease, thyroid disease

12

Social History



Non-smoker



Non alcoholic beverage drinker



College undergraduate



Unemployed

13

Physical Examination

    Drowsy , not in cardiorespiratory distress, wheelchair-borne BP= 80/50 -->90/60 HR=105 RR=21 T=36.7C Wt=59 kg Ht=160 cm BMI=23 Pale palpebral conjunctivae lymphadenopathy , anicteric sclerae, no tonsillopharyngeal congestion, no cervical Equal chest expansion, clear breath sounds, no crackles, no wheezes 14

Physical Examination

   Adynamic precordium, murmurs tachycardic , regular rhythm, distinct S1 and S2, no appreciated Globularly distended abdomen , normoactive bowel sounds, tenderness ill-defined mass on deep palpation on the right lumbar region, (+) No gross deformities of the extremities, II pedal edema, right, decreased pulse on right , no cyanosis, no tenderness, grade 15

      52/F Diabetic Schizophrenic Enlarged abdomen Drowsy Tachycardic

Salient Features

    Pale palpebral conjuctivae (+) tenderness on right lumbar region Decreased pulse on right extremity Grade II pedal edema, right 16

Initial Impression

1.

Urosepsis secondary to Acute Pyelonephritis, Perinephric Abscess 2. Peripheral vascular disease, right leg 3. Diabetes Mellitus Type 2 4. Chronic Schizophrenia

17

UROSEPSIS

18

At the ER

  Drowsy Hypotension: BP 80/50   Tachycardic: 105bpm Blood WBC: 17.73x10

3 /L, segmenters 0.87

 Urinalysis: bacterial 44,208/hpf 19

8/7 8/11 8/13 8/19 Hgb Hct RBC WBC Eos Stabs Mye Meta Seg Lymp Mono Plt

2.0

2.0

87 4.0

3.0

172 8.5

27.5

3.55

17.73

2.0

3.0

1.0

83 7.0

4.0

178 7.3

24.5

3.06

17.65

9.10

29.8

3.64

18.57

12.5

39.5

4.76

9.58

1.0

2.0

89 5.0

4.0

300 84 11 4.0

324

8/24 8/28 NV

1.0

1.0

84 10 4.0

318 12.5

39.8

4.74

14.36

11.5

38.4

38.4

18.63

12.3 15.3

35.9 44.6

4.5-5.1

4.4 11.0

0-4 0.0

2.0

1.0

83 9.0

5.0

372 40-70 22-43 0-7 150 450 20

At the ER

  Hypotension: BP 80/50, px noted drowsy Tachycardic: 105bpm   Blood WBC: 17.73x10

3 /L, segmenters 0.87

Urinalysis: bacterial 44,208/hpf 21

Urinalysis Physical and Chemical Color Transparency pH Reaction Specific Gravity Sugar Protein Ketones Nitrites Leucocytes Esterase Blood RBC WBC Epithelial Cells Bacteria 8/7

Yellow Cloudy 7.5

1.010

Negative +2 Negative Negative Negative +3 7 4 10 44208

8/21

Yellow Clear 6.5

1.010

Negative Negative Negative Negative Trace +2 1 4 1 1

Normal Value

Yellow Clear 4.8-7.8

1.010-1.025

Negative Negative Negative Negative Negative Negative 0-2 0-3 0-3 0-50 22

At the ER

 IVF: PNSS 1L , 200ml fast drip then regulated 120ml/hr  Diagnostics: Na, K, crea, CBG, blood CS, urine CS  Therapeutics: Ertapenem 1g IV q24 Amikacin 500mg IV x 1 dose  Referred to Nephrology, Psychiatry 23

Na K 8/7

120 3.7

BUN Crea

1.5

Alb

1.4

ALT RBS Urine Na Urine Os Urine crea

135 9.0

356 47

8/9

136

8/10

136

8/11

141

8/13

145

8/14

147

8/24

137

8/28 NV

140 136-145 2.8

3.3

4.0

3.6

3.0

3.6

3.5

3.5-5.1

23 0.6

0.80

0.90

0.80

0.90

0.90

0.6-1.0

3.4-5.0

42 30-65 250-900 24

2

nd

HD

  Still with febrile episodes Urine CS: E.coli 100,000 cfu/ml and Grp B Streptococci (Enterococci) 100,000 cfu/ml  Tx: Clindamycin 300mg/tab, 1 tab q8  Episodes of decreased urine output  Foley catheter inserted  Furosemide 40mg tablet, ½ tablet once daily 25

8/7: Urine CS 8/9: Blood CS

• E.coli 100,000 cfu/ml • Grp B Streptococci (Enterococci) 100,000 cfu/ml • Sensitive: Amikacin, Ampicillin/Sulbactam, Cefuroxime, TMP/SMX, Nitrofurantoin, Ampicillin, Penicillin, Ertapenem, Ciprofloxacin • No growth after 5 days of incubation

8/11: Urine CS

• C. albicans >100,000 cfu/ml 26

6

th

HD

  Still moderate-grade fever Abdomen still distended  Referred to Urology service for planned nephrectomy  Piperacillin tazobactam 4.5g IV infusion for 8 hours every 8 hours 27

7

th  Right renal exploration, evacuation of perineprhic abscess, and right nephrectomy under GA

HD

Impression 8/14: Right kidney & ureter histopathology

• Nephrolithiasis with acute and chronic pyeloneprhitis • Chronic ureteritis 28

Impression 8/14: Right Peri renal abscess CS 8/14: Peri-renal abscess AFB Concentration

• Light growth of E. Coli • Sensitive: Amikacin, Ampicillin/Sulbactam, Cefuroxime, TMP/SMX, Ampicillin, Ertapenem, Ciprofloxacin • No acid fast bacilli seen 29

30

31

15

th

HD

 Ertapenem (day 7) was discontinued and started on Cefixime 200mg capsule once a day and Clindamycin 300mg 3 times a day 32

Peripheral Vascular Disease

33

3

rd  Right foot noted cyanotic and cold  Compression stockings and warm blanket  PT and PTT  Heparin drip 24,000 units in D5W 250ml at 1,000 units/hr

HD

34

35

36

37

8/11 8/22 8/23 8/24 8/25 8/26 8/26 8/27 8/28 NV PTT px

26.4

122.2 33.5

36.2

89.9

47.0

38.2

34.6

34.2

25.1 33.9

PTT cont

28.4

28.1

30.2

28.4

29.0

29.7

28.5

28.2

28.3

PT px

13.6

13.0

50.9

17.2

12.7

14.3

10.6 13.3

74.4

12.8

48.1

79.4

63.7

PT Act

69.1

PT cont

11.7

PT INR

1.16

11.7

1.1

11.7

4.44

11.7

1.47

11.7

1.08

11.7

1.22

38

5

th

HD

• Referral to Vascular Surgery

Impression 8/12: Color Doppler of Deep Veins, both lower extremities

• No demonstrable thrombosis in this study

8/12: Color Doppler of Arteries, both lower extremities

• Normal studies of the arteries • Low velocity monophasic flow in the right, with no flow in the deep femoral artery and calf arteries 39

8/12: MRI of Whole Abdomen

•

Primary consideration is a renal abscess with extension to perinephric space & right abdominal wall with involvement of the right iliacus muscle

•

Foci of increased susceptibility within the right kidney may represent calcifications

•

Intestinal ileus

•

Normal findings of liver, gallbladder, pancreas, spleen, left kidney, adrenal glands, and urinary bladder

40

8/12: MRA of Abdominal Aorta & Lower Peripheral Vessels Impression

• Intimal irregularities in abdominal aorta due to atherosclerotic disease. The aortic bifurcation occurs at a normal level with no evidence of narrowing or aneurysm • Single patent renal arteries both sides showing normal caliber • The common, internal, and external iliac arteries are normaly visualized. There is 1.1cm filling defect seen in the proximal segment of the right common iliac artery. Thrombus formation is considered .

• Both common femoral arteries have normal calibers, smooth walls and course, caliber, and distribution • The superficial femoral arteries appears normal, especially within the adductor canal • The popliteal arteries shows normal course and no irregularities in its caliber • Faint flow signals noted in right posterior tibial artery. The right anterior tibial & peroneal arteries are normal in course and caliber • The left posterior tibial, anterior tibial and peroneal arteries are normal in course and caliber 41

10

th

HD

  3 rd post-nephrectomy day No febrile episodes  Noted progression of the cyanosis of right foot from the initial 1 st digit further to the plantar forefoot area  Heparin drip was increased to 1,100 units per hour 42

12

th

HD

  5 th post-nephrectomy day Referred to radiology service for right femoral angiography

8/19: Arteriogram, Right Lower Extremity

•

Distal small vessel disease with occlusions involving the peroneal, anterior and posterior tibial arteries. Presence of meniscus in the margins of the occlusion in the anterior tibial artery suggests the possibility of clot embolization especially since the anterior tibial and peroneal arteries were normal in the recent MRA

•

Mild stenosis, origin of the right common iliac artery

43

12

th

HD

  Suggested below the knee amputation, however relatives expressed to try less invasive procedure Embolectomy of the right anterior tibial artery under local anesthesia was done immediately  Post-procedure heparin drip was resumed at 1,200 units per hour.

44

16

th   9 th post-nephrectomy day 4 th  post-embolectomy day Warfarin 5mg tab OD started  Heparin drip adjusted at 1,000 units per hour

HD

45

18

th

HD

    11 th post-nephrectomy day 6 th post-embolectomy day note of progression of hemorrhagic area above the level of the patient’s right ankle   Doppler evaluation, there is a faint signal heard beyond the popliteal area Heparin drip increased to 700 units Vascular Surgery service evaluated the progression at this time is irreversible and that below the knee amputation is already needed 46

19

th

HD

   12 th post-nephrectomy day 7 th post-embolectomy day Patient underwent below the knee amputation  Aspirin 80mg OD started 47

Impression 8/21: Right leg thrombus

• Consistent with thrombus, right leg

8/24: Ultrasound of the Mons Pubis

• Small abscesses considered, Right side of the mons pubis 48

23

rd

HD

    16 th post-nephrectomy day 11 th 4 th post-embolectomy day post-BKA day patient discharged improved  Take home meds:Clindamycin 300mg TID for 7 days and Ciprofloxacin 500mg BID for 7 days.

8/26: UTZ of the Whole Abdomen Impression

• S/P right nephrectomy, minimal complex fluid collection in right renal fossa, probably residual abscess • Normal liver, gallbladder, biliary tree, pancreas, spleen, left kidney, urinary bladder, uterus/adnexae 49

DIABETES MELLITUS

50

1

st

HD

   Episodes of drowsiness Elevated CBGs (highest at 294mg%) Referred to Endocrine service  NGT initially inserted and given osteorized feeding     CBG monitoring 4 times a day Managed with insulin therapy Diet subsequently modified Discharge home medication: Glimepiride 1mg, ½ tablet before breakfast 51

   

Final Impression

Urosepsis secondary to Acute Pyelonephritis; Perinephric Abscess ;S/P Nephrectomy,right Peripheral Arterial Occlusion, S/P BKA, right Diabetes Mellitus type 2 Chronic Schizophrenia, Paranoid type 52

Discussion

PERINEPHRIC ABSCESS

53

Abscess

  Localized collections of purulent inflammatory tissue caused by suppuration buried in a tissue, an organ, or a confined space * In time, may become walled off and replaced by connective tissue * Robbins and Cotran Pahologic Basis of Disease 7 th ed.

54

Urosepsis

  Sepsis syndrome due to urinary tract infection Includes clinical evidence of UTI plus 2 or more of the following:     T > or = 38C or < 36C HR > 90bpm RR > 20/minute or PaCO2 < 32mmHg WBC >12,000 or <4,000 or > 10% band forms 55

Perinephric Abscess

  Collection of suppurative material in the perinephric space between Gerota’s fascia and the renal capsule* Evolves from the extension of an intrarenal suppurative process, either from pyeloneprhitis or urinary extravasation due to obstruction (i.e. by kidney stones) with compounding infection + * Tsukagoshi et al.Perinephric Abscess Secondary to a Staghorn Calculus.Observations De Cas.2006:285-6 + Deck et al.Perinephric Abscess in the Neurologically Impaired.2001:477-9.

56

Perinephric Abscess

 30% hematogenous dissemination from sites of infection (i.e. wound, furuncles, pulmonary) 57

Epidemiology

   Uncommon, but potentially lethal complications of urinary tract infection* Incidence ranges from 1-10 cases for every 10,000 hospital admissions High mortality rate of 20-40% * Coelho et al. Renal and Perinephric Abscesses:Analysis of 65 Consecutive  Cases.World Journal Of Surgery.2007:431 58

Etiology

    Infecting bacteria are usually g(-) enteric bacilli and occasionally g(+) cocci when the infection is of hematogenous origin Most common agent: E.coli and Proteus species* Bacteria associated with infection stones and fungi have been described* Often infections are polymicrobial * Deck et al.Perinephric Abscess in the Neurologically Impaired.2001:477-9.

59

Predisposing Factors

  DM (60-90%) and previous urologic surgery Others: hx of pyeloneprhitis, urinary calculi, renal or ureteric obstruction, neurologic impairment, GU-TB(strictures), PCKD, immunosuppresion, and injection drug use* * Paily, Rejith.Perinephric Abscess from Insulin Syringe Use.Med Sci.2004:47-8.

60

Infections in Diabetics

   Many specific infections are more common in diabetic patients, and some occur almost exclusively in them Other infections occur with increased severity and are associated with an increased risk of complications Several aspects of immunity are altered in patients with diabetes  PMN leukocyte function is depressed, particularly (+) acidosis 61

Infections in Diabetics

    Leuckocyte adherence, chemotaxis, and phagocytosis may be affected Antioxidant systems involved in bactericidal activity may also be impaired Cutaneous responses to antigen challenges and measures of T-cell function may be depressed Evidence that improving glycemic control in patient improves immune function 62

  

DM and UTIs

Several controlled studies demonstrated a higher incidence of bacteriuria (by a factor of 2-4) in diabetic women than in nondiabetic women * Upper urinary tract is involved in up to 80% In one series of patients with perinephric abscess, 36% had DM * , secondary to diabetic neuropathy-induced bladder dysfunction, urologic manipulation, and high glucose concentrations impairing PMNs * Nirmal et al:Infections in Patients with DM.NEJM 1999;1906-7 63

Clinical Features

   Development can be insidious and presentation can be both nonspecific and deceptive Most common s/sxs: fever, flank or abdominal pain, chills, dysuria, weight loss, lethargy, anorexia, elevated glucose in diabetics, hematuria, pyuria, sepsis, persistent fever despite antibiotics Physical findings: flank or costovertebral tenderness, palpable abdominal mass 64

Diagnosis

      Unilateral flank pain and/or mass, fever Anemia and leukocytosis on CBC Azotemia may be present Positive blood cultures (<50%) Pyuria (75%), proteinuria, and hematuria (30%) on urinalysis, positive urine cultures (75%) No response to treatment for acute pyelonephritis 65

Diagnosis

 Abdominal radiographs   Abnormal in up to 60% (-) psoas border, enlarged kidney, obliteration of renal shadow, retroperitoneal gas, perinephric gas bubbles (pathognomonic) 66

Diagnosis

 Ultrasonography    Useful and non-invasive but is false-negative in up to 36% of cases Demonstrate fluid collections that may be poorly visualized with radiography Screening tool to assess for obstructive uropathy, exclude another intraabdominal/retroperitoneal process, and exclude suppurative renal complications 67

Diagnosis

 CT Scanning    Modality of choice; more sensitive and accurate in diagnosing intra-abdominal abscess (90%) than ultrasonography Typical appearance is that of a soft-tissue mass (20 Hounsfield unit) with a thick wall that may enhance after introduction of IV contrast Retroperitoneal hematoma, urinoma, and tumor may be differentiated from an abscess 68

Diagnosis

 Magnetic Resonance Imaging  Offers no advantave over CT but may be considered as alternative to contrast-enhanced CT in patients with a contraindication to iodinated contrast administration 69

Treatment

  Mainstay of treatment is interventional treatment: percutaneous or surgical drainage of the abscess cavity and drainage of the obstructed urinary collecting system, if present Antibiotics are used as adjunct to help control sepsis and prevent spread of infection; broad spectrum coverage of g(+) and g(-) is required 70

Treatment

  Evaluate to determine whether immediate nephrectomy, delayed nephrectomy or definitive treatment of the urinary obstruction with renal preservation is appropriate When kidneys are nonfunctioning or severely infected (emphysematous pyelonephritis, diffusely damaged parenchyma), and septic patients requiring urgent intervention, nephrectomy is the classic treatment 71

Treatment

 Percutaneous drainage    Success rate for single unilocular abscessess 82% vs multilocular 45% Contraindicated to (+) coagulation disorders and calcified mass Poor results in: underlying ds such as DM and calculi, thick purulent discharge, (+) fungal infection, markedly diseased nonfunctioning kidneys 72

Treatment

 Open/Surgical drainage   Simpler and safer drainage of septated abscesses Allows anatomic examination and a more exact delineation of the extension process 73

Complications

     Life-threatening sepsis Renal failure Abscess extension along psoas muscle, groin, perineum, vagina, or scrotum Perforate the peritonium, bladder, colon, spleen Erode through diaphragm into pleura, lungs, pericardium 74

Conclusion

 Perinephric abscess:     May present with non-specific signs and symptoms Carry a significant mortality risk Strong correlation between late diagnosis and high mortality Successfully managed by immediate interventional treatment 75