Carbuncle kidney

Kidney carbuncle - purulent-necrotic lesion with the formation of a limited infiltrate in the cortical substance of the kidney.

In recent years, the frequency of the carbuncle of the kidney has increased significantly.

[1], [2],

Causes of the carbuncle kidney

Kidney carbuncle or is a form of purulent pyelonephritis, or occurs due to the penetration of the hematogenous by infection into the cortex substance of the kidney in the presence of any purulent foci in the body. Often, the carbuncle of the kidney is preceded by diseases of the upper respiratory tract, pustular skin lesions, furunculosis, carbuncle, panaritium, mastitis, peritonsillar abscess, etc. By the time the kidney is damaged, patients often forget about the primary purulent focus. Normally, healthy kidneys are involved. Perhaps the occurrence of carbuncle in violation of the passage of urine due to obstruction of the ureter calculus, the presence of bladder cancer and prokaty, prostate adenoma, pregnancy, urethral stricture. Ovarian cancer and uterus.

There are various mechanisms for the formation of the carbuncle of the kidney:

• a septic embolus enters the renal artery, causing a septic infarction of the kidney and a carbuncle;
• a branch of the renal artery may not be completely obturated with the embolus, but what is the further spreading infection?
• the infection is localized in one place, from which it spreads to the kidney tissue, causing necrosis and supuration.

Consequently, for the formation of a carbuncle, it is not necessary to have a large microbial embolus occluding a large renal vessel. In the area surrounding the affected area, an inflammatory process occurs with the formation of a granulation protective shaft. The infiltrate extends to the area of the cups or renal pelvis. In the renal cellulose, reactive edema develops and then purulent inflammation, often with the formation of perirenal abscess. The inflammatory focus may not melt for a long time, as a result of which the renal tissue is soaked due to extensive infarction around the circumference, the renal tissue becomes saturated with pus. The same picture develops as in the case of the carbuncle of the skin. This gave grounds for Israel (1881) to call the described lesion the carbuncle of the kidney. Kidney carbuncle has different sizes - from lentil grain to chicken eggs.

The most frequent pathogens of the carbuncle of the kidney are representatives of gram-negative (E. Coli, Proteus, Pseudomonas aeruginosa) and mixed flora. After breaking through the infected contents of convoluted tubules of the second order into the connective tissue of the kidney, inflammation of the interstitial tissue begins. The process is pronounced focal. In the connective tissue of the kidney, one can see leukocyte infiltrates, the formation of leukocyte “muffs” around the collecting tubules. In the lumen of the tubules and capsules of the glomeruli determine a large number of microorganisms, which indicates the continuing aggression. With timely assistance, the inflammatory process may subside. If the inflammation is not treated, inflammatory infiltration of the walls occurs in the intraorgan arteries passing through the foci of inflammation, elastopharyosis occurs, causing thrombosis of arterioles with complete cessation of blood flow. As a result, the kidney zone supplied by the affected artery undergoes acute ischemia, up to and including a heart attack.

In the usual course of acute pyelonephritis, the ischemic (necrotized) area shrinks, and one of the invading scars appears in the kidney parenchyma.

However, another course is possible, leading directly to the occurrence of a carbuncle of the kidney. At this stage, a superinfection of the ischemic (necrotized) part of the kidney occurs. Bacteria trapped in necrotic or sharply ischemic tissues receive favorable conditions for reproduction.

The beginning purulent-necrotic process leads to the formation of a cone-shaped (repeating the structure of the ischemic zone of the kidney), separated from the surrounding renal tissue of the purulent-necrotic disintegration of the carbuncle.

Essential in the etiology of carbuncle is attached to pathogens of necrotizing inflammation. Being introduced into sharply ischemic tissue, the proteus and the pseudo-purulent bacillus determine its final purulent-necrotic decay.

According to the literature, the carbuncle of the kidney is 2 times more often localized to the right (mainly in the upper segment). The inflammatory process in 95% of patients develops in one kidney, but can be bilateral. Sometimes in one kidney there are multiple carbuncles.

In 84% of patients, the carbuncle of the kidney occurs on the background of various associated diseases that weaken the body's defenses (diabetes, coronary heart disease (CHD), cardiosclerosis, common atherosclerosis, chronic cholecystopancreatitis, chronic inflammation of the internal genital organs in women, etc.)

The combination of a carbuncle of the kidney and apostematic pyelonephritis is observed in 38% of patients.

[3], [4], [5]

Pathogenesis

Pathogens of necrotizing inflammation have significant importance in etiology of carbuncle. Penetrating sharply into ischemic tissue, Proteus and Pseudomonas aeruginosa are responsible for its final necrotic decay.

According to literature, carbuncle of kidney is 2 times more often localized to right (mainly in upper segment). Inflammatory process in 95% of patients develops in single kidney, but may be also bilateral. Sometimes there are multiple carbuncles in one kidney.

In 84% of patients kidney carbuncle occurs against various opportunistic diseases that weaken body's defenses (diabetes, coronary heart disease (CHD), cardio, widespread atherosclerosis, chronic cholecystopancreatitis, chronic inflammation of internal genital organs of women, and others)

Combination of kidney carbuncle and apostematous pyelonephritis is observed in 38% of patients.

Symptoms of the carbuncle kidney

The disease can occur latently and violently, with typical symptoms of a carbuncle of the kidney. The most persistent symptoms of a carbuncle kidney are chills, high body temperature, nausea, vomiting, fatigue, and lack of appetite. Severe local symptoms occur early: dull, aching pain in the lumbar region, pain on palpation, a positive symptom of Pasternacksky, often an increase in the kidney. The symptoms of a kidney carbuncle depend on the severity of the inflammatory process, its localization, the stage of the disease, complications of the urinary tract, kidney function and the presence of associated diseases. If the carbuncle is in the upper segment of the kidney, the infection can spread through the lymphatic ducts and go to the pleura.

Irritation of the posterior leaflet of the parietal peritoneum is accompanied by signs that can simulate the clinic of an acute abdomen. With the localization of the carbuncle in the upper segment of the kidney, the inflammatory infiltrate can go to the adrenal gland, causing adrenal hypofunction syndrome. Soreness, tension and swelling in the lumbar region are late signs of the disease. All patients increased leukocyte levels (10-20x109 / l). In patients with primary carbuncle, the urine is sterile at an early stage of the disease. Later, moderate pyuria appears. The typical symptoms of a carbuncle kidney are rare. The erased and atypical forms of the carbuncle of the kidney proceed without hyperthermia and pain; unchanged hemogram or with changes not characteristic of acute inflammatory processes; without changing the composition of urine or with atypical disorders; with the prevalence of symptoms of common disorders and previous diseases or conditions. In many patients, the kidney carbuncle occurs under different masks: cardiovascular, abdominal, gastrointestinal, pulmonary, neuropsychomorphic, nephro and hepatopathic, thromboembolic diseases.

With a carbuncle of the kidney, which proceeds according to the type of cardiovascular diseases, the symptoms of damage to the cardiovascular system come to the fore. So, with a general tendency to tachycardia and arterial hypotension, an increase in arterial pressure, bradycardia are possible. Symptoms of acute myocardial dystrophy, right ventricular insufficiency are expressed.

There are focal disorders of myocardial blood supply, intracardiac conduction, and peripheral edema of the circulatory type are possible. This is mainly observed in the elderly and senile age. Usually they are admitted to therapeutic or cardiology departments with a diagnosis of acute heart failure, myocardial infarction, etc. Often, the final diagnosis is established only during the autopsy.

Patients with "abdominal" clinical manifestations complain mainly of acute diffuse or localized abdominal pain. Often vomiting, expressed peritoneal symptoms. Often, such patients first enter the general surgical wards.

In patients with gastrointestinal manifestations, the carbuncle kidney disease begins with pain in the epigastrium. There is frequent painful bowel movement, accompanied by nausea and vomiting. The feces contain blood and mucus. Such patients are often hospitalized in the infectious diseases ward with a diagnosis of acute dysentery.

With late diagnosis and inadequate treatment, pneumonia, pulmonary insufficiency, and pulmonary edema are often observed as a result of hematogenous toxico-septic lesion of the lungs. Sometimes the pulmonary symptoms may acquire independent significance, causing incorrect diagnosis and treatment tactics.

Possible neuropsychomorphic symptoms. In such patients, symptoms of motor arousal, delirium, tonic and clonic convulsions, symptoms of stem disorders dominate. Only a qualified analysis of neurological symptoms allows us to establish their secondary (intoxication) genesis.

Sometimes with weak severity of local symptoms and without changing the composition of the urine, symptoms of severe liver damage — acute jaundice and an increase in liver size — come to the fore. Severe toxic-septic liver damage is observed in elderly and debilitated patients with multiple and bilateral carbuncles of the kidneys. They sometimes come to the fore the symptoms of acute renal failure or hepatic-renal failure.

Sometimes there is a septic thromboembolism of the pulmonary artery or brain. Usually these patients die. Carbuncle buds are found only at an autopsy.

[6], [7], [8]

Diagnostics of the carbuncle kidney

Diagnosis of the carbuncle of the kidney is difficult, since there are no pathognomonic clinical signs. The diagnosis in most cases is made presumably on the basis of an acute, septic onset of the disease, the presence of local pain and X-ray and ultrasound data.

Often patients first diagnose: bronchopneumonia, kidney tumor, cholecystitis, pancreatitis, appendicitis, urolithiasis, pyonephrosis, acute pyelonephritis. With a single primary carbuncle of the kidney, the urine is normal or it exhibits changes typical of acute inflammatory processes in the urinary system (proteinuria, leukocyturia, bacteriuria, microhematuria). In the blood, characteristic for non-specific inflammatory process changes are noted - high leukocytosis, increased ESR, hypochromic anemia, hypoproteinemia. The diagnosis is made easier by the communication of the abscess with the renal pelvic system, as this results in massive leukocyturia.

The greatest difficulties are observed in cases where the abscess is located in the cortical substance of the kidney and the patency of the upper urinary tract is not disturbed.

Radionuclide kidney scanning, ultrasonography and CT are considered the most objective diagnostic methods.

On a review radiograph, you can detect an increase in the size of one of the segments of the kidney, the disappearance of the contour of the lumbar muscle on the affected side, the shadow of urinary calculi. Of the indirect signs - a decrease in the respiratory excursion of the diaphragm, sometimes - effusion in the phrenic sinus.

With excretory urography, a decrease in the function of the corresponding kidney is noted in 6% of patients. One can see the deformation and contraction of the renal pelvis, and in some patients the displacement and abrasion of the contour of the cups. Sometimes on the radiograph reveal signs characteristic of a kidney tumor. On computerized tomograms, the carbuncle of the kidney appears as a plot of density equal to the surrounding tissue or having increased transparency. On a spiral computer tomogram with contrast, areas of non-uniform structure are determined, in which there is no accumulation of contrast material surrounded by a rim of increased density around the periphery. When carrying out ultrasound, the following signs of a kidney carbuncle are distinguished:

• an increase in the thickness of the cortical layer in the area of carbuncle formation;
• irregularity and bulging of the kidney contour at the site of carbuncle formation;
• thickening of the walls of the pelvis, cortical and cerebral layers;
• reduced kidney excursions.

In the Doppler study of the lesion, a significant depletion of the vascular pattern or an avascular zone around the forming carbuncle is determined.

Kidney carbuncle must be differentiated from infectious processes. Tumors of the parenchyma of the kidney, festering solitary cyst of the kidney, acute cholecystitis, subphrenic abscess, pancreatitis, kidney tuberculosis. In unclear situations, CT of the kidney helps to perform differential diagnosis.

[9], [10], [11], [12]

Treatment of the carbuncle kidney

[13],

Surgical treatment of the carbuncle kidney

Emergency operation shown. It starts with lumbotomy, the release and examination of the kidney. Surgery depends on the nature of the pathological changes, the general condition of the patient and the function of the opposite kidney. In most patients, an autopsy and drainage of the carbuncle is performed. The carbuncle zone is dissected with a cruciate incision until fresh blood is found in the depth of the wound. In cases of destruction of a large part of the kidney or in case of multiple lesions, nephrectomy is performed.

Intensive antibacterial treatment of the kidney carbuncle as an independent method can be recommended only in the initial stage of the disease with active observation of the urologist.

A method for the combined use of antibacterial therapy with the introduction of cryoprecipitate has been developed. Its introduction contributes to an increase in the concentration of fibronectin in the blood, which in turn leads to the restoration of blood flow in the ischemic zone, penetration of antibacterial agents into the inflammatory focus and the gradual regression of the inflammatory process in the kidney.

This method of treatment in patients with carbuncle allows to achieve positive clinical results in 84.1%. According to the ultrasound, comes the restoration of blood flow in the area of the carbuncle and the disappearance of signs of kidney ischemia.

[14], [15]

Prevention

Kidney carbuncle can be prevented if acute pyelonephritis and purulent inflammatory processes of various localization are timely and adequately treated. In patients with a single carbuncle and undisturbed urodynamics with timely surgical intervention, the prognosis is favorable. After surgery, patients need regular follow-up.

[16], [17], [18], [19], [20]