Urol Radiol 12:91-93 (1990)
Urologic Radiology © Springer-VerlagNewYorkInc.1990
Splenic Abscess Arising by Direct Extension from a Perinephric Abscess J . H . Reese, 1 R . U . A n d e r s o n , 2 a n d G. F r i e d l a n d 1 IDepartment of Surgery, Division of Urology, Stanford University Medical Center, and Veterans Administration Medical Center, Palo Alto; and 2Department of Surgery, Division of Urology, Santa Clara Valley Medical Center, San Jose, California, USA
Abstract.
A case o f a p e r i n e p h r i c a b s c e s s i n v a d i n g the s p l e e n i n a 2 5 - y e a r - o l d w o m a n w i t h b l a d d e r e x t r o p h y is r e p o r t e d . T r e a t m e n t u t i l i z e d b o t h perc u t a n e o u s d r a i n a g e a n d o p e n surgery. P e r i n e p h r i c abscesses h a v e n o t b e e n p r e v i o u s l y r e p o r t e d to ext e n d i n t o t h e spleen.
Key words:
Abscess, p e r i n e p h r i c - - S p l e e n - - Percutaneous drainage.
A b s c e s s e s o f the p e r i r e n a l space are m o s t c o m m o n l y confined within an anatomic envelope provided by G e r o t a ' s fascia; i n t r a p e r i t o n e a l e x t e n s i o n s are u n u s u a l a n d are c o m m o n l y i n t o a v i s c u s [1, 2]. W e r e p o r t a case t h a t is u n i q u e i n t w o respects. First, it is the o n l y r e p o r t o f a p e r i n e p h r i c abscess i n v o l v i n g t h e s p l e e n . S e c o n d , d e s p i t e t h e fact t h a t t h e abscess e x t e n d e d i n t o the spleen, n e a r the s p l e n i c v e i n , it was i n i t i a l l y successfully d r a i n e d p e r c u t a n e o u s l y .
Case Report The patient was a 25-year-old white woman with a history of bladder extrophy and a subsequent ureterosigmoidostomy. She had a long history of pyelonephritis, as well as a known left lower pole calculus within a calyceal diverticulum. She was seen in the
Address reprint requests to: Jeffrey H. Reese, M.D., Veterans Administration Medical Center (112C), 3801 Miranda Avenue, Palo Alto, CA 94304, USA
emergency room 2 weeks prior to admission with left flank pain and a white blood cell count (WBC) of 13,800. An intravenous urogram (IVU) failed to reveal a significant abnormality. Despite a 2-week course of oral cinoxacin, she presented again on the day of admission with a fever of 102° F, chills, and a WBC of 23,500 with a left shift. A renal ultrasound showed a left lower pole mass and a computerized axial tomographic scan (CT) revealed a large perinephric fluid collection with apparent extension into the spleen (Fig. 1). The collection was successfully drained pereutaneously with two 12-Fr J catheters. Culture revealed gamma streptococcus. The patient was treated with 7 days of parental antibiotics followed by a 2-week course of oral antibiotics. A sinogram obtained 1 week following admission showed a persistent abscess cavity in continuitywith the lower pole renal calculus (Fig. 2). The patient was discharged with a percutaneous J tube in place. A repeat sinogram 3 weeks following initial drainage of the abscess now revealed what appeared to be a direct connection between the abscess cavity and the splenic parenchyma and splenic vein (Fig. 3). Due to the fear of erosion into the splenic vasculature, it was elected to remove the drain and observe the patient. The patient presented 6 weeks later with severe left flank pain. A repeat CT scan revealed a reaccumulation of fluid between the kidney and the spleen, and open exploration was undertaken. At the time of surgery, the kidney and spleen were noted to be densely adherent to each other with a 1 cm tract between the two organs. The renal calculus was removed via a nephrotomy, and perinephric fat was interposed between kidney and spleen to prevent recurrence. The patient had an uneventful postoperative course. A repeat CT scan (Fig. 4), obtained 5 months following surgery, revealed no evidence of recurrent abscess.
Discussion P e r i n e p h r i c abscesses are rare a n d o f t e n l i f e - t h r e a t ening infections. T h e i r incidence varies from 0.9-4 cases p e r 10,000 h o s p i t a l a d m i s s i o n s , w h e r e a s o n l y 0 . 2 % o f u r o l o g i c p r o c e d u r e s m a y be a t t r i b u t e d to this e n t i t y [3]. D u e to the w e l l - d e f i n e d b o u n d a r i e s o f G e r o t a ' s fascia, these i n f e c t i o n s are a l m o s t a l w a y s
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J.H. Reese et al.: Perinephric Abscess
Fig. 1.
CT scan showing a large perinephric fluid collection with apparent extention into the spleen.
Fig. 2.
Sinogram showing the abscess cavity in continuity with the lower pole calculus (arrows) and the renal collecting system.
Fig. 3.
Sinogram showing contrast draining into the splenic parenchyma and splenic vein (arrows).
Fig. 4.
CT scan showing resolution of the abscess.
confined within the perinephric space. When extension occurs it does so most commonly inferiorly along the psoas muscle where the leaves of Gerota's fascia do not fuse [1]. Although rare, these abscesses may extend into the abdominal cavity or its contents. In an extensive review of the world's literature, Abeshouse [2] reported 158 cases ofperinephric infections fistulizing into the peritoneal cavity or its contents. The most common site was the colon (89 cases), whereas the next most common site was the peritoneal cavity itself (52 cases). Other abdominal sites included the stomach duodenum and uterus [2]. A large retrospective review of 117 cases of perinephric abscess from Charity Hospital in New Orleans revealed no cases of extension to visceral organs [4]. A more recent series of 71 cases of perinephric abscess en-
countered at the University of Southern California Medical Center noted one case of colonic perforation [5]. Our case represents the first reported incident o f a perinephric abscess involving the spleen. Clearly, an abscess fistulizing to the spleen represents an extraordinarily rare event. However, it does illustrate the point that virtually any organ contiguous to the kidneys may be the target for a fistula arising as a consequence of a perinephric abscess. The abscess in our patient was initially successfully treated by percutaneous drainage, although the abscess did recur 6 weeks later probably related to persistence of infection in and around the stone in the calyceal diverticulum. Unfortunately, due to its position within a calyceal diverticulum, the stone could not readily be treated by either percutaneous lithotripsy or extracorporeal shock wave lithotripsy.
93
J.H. Reese et al.: Perinephric Abscess H a d this not been the case, it is likely that percutaneous drainage would h a v e p e r m a n e n t l y cured o u r patient's abscess. In this patient, contrast m e d i a could be d e m onstrated to pass directly into the splenic parenc h y m a a n d splenic vein. O n e concern in treating this patient percutaneously was the risk o f m a s s i v e h e m o r r h a g e . H o w e v e r , no bleeding e v e r occurred. W e c a n n o t generalize f r o m a single case, b u t perc u t a n e o u s drainage o f a perinephric abscess extending into the spleen seems a reasonable option. It is d e a r l y i m p e r a t i v e that drainage o f the abscess cavity m u s t be a c c o m p a n i e d by t r e a t m e n t o f the p r i m a r y source o f infection.
References 1. Love L, Baker D, Ramsey R: Gas producing perinephric abscess. Am J Roentgenol Radium Ther Nucl Med 119:783-792, 1973. 2. Abeshouse BS: Renal and ureteral fistula of the visceral and cutaneous types: a report of four cases. Urologic Cutaneous Rev 53:641-674, 1949 3. Sheinfeld J, Erturk E, Spataro RF, Cockett AT: Perinephric abscess: current concepts. J Urol 137:191-194, 1987 4. Atcheson, DT: Perinephric abscess with a review of 117 cases. J Urol 46:201-208, 1941 5. Salvatierra O, Bucklew B, Morrow J: Perinephric abscess: a report of 71 cases. J Urol 98:296-302, 1967
Urologic Radiology © Springer-VerlagNewYorkInc.1990
Splenic Abscess Arising by Direct Extension from a Perinephric Abscess J . H . Reese, 1 R . U . A n d e r s o n , 2 a n d G. F r i e d l a n d 1 IDepartment of Surgery, Division of Urology, Stanford University Medical Center, and Veterans Administration Medical Center, Palo Alto; and 2Department of Surgery, Division of Urology, Santa Clara Valley Medical Center, San Jose, California, USA
Abstract.
A case o f a p e r i n e p h r i c a b s c e s s i n v a d i n g the s p l e e n i n a 2 5 - y e a r - o l d w o m a n w i t h b l a d d e r e x t r o p h y is r e p o r t e d . T r e a t m e n t u t i l i z e d b o t h perc u t a n e o u s d r a i n a g e a n d o p e n surgery. P e r i n e p h r i c abscesses h a v e n o t b e e n p r e v i o u s l y r e p o r t e d to ext e n d i n t o t h e spleen.
Key words:
Abscess, p e r i n e p h r i c - - S p l e e n - - Percutaneous drainage.
A b s c e s s e s o f the p e r i r e n a l space are m o s t c o m m o n l y confined within an anatomic envelope provided by G e r o t a ' s fascia; i n t r a p e r i t o n e a l e x t e n s i o n s are u n u s u a l a n d are c o m m o n l y i n t o a v i s c u s [1, 2]. W e r e p o r t a case t h a t is u n i q u e i n t w o respects. First, it is the o n l y r e p o r t o f a p e r i n e p h r i c abscess i n v o l v i n g t h e s p l e e n . S e c o n d , d e s p i t e t h e fact t h a t t h e abscess e x t e n d e d i n t o the spleen, n e a r the s p l e n i c v e i n , it was i n i t i a l l y successfully d r a i n e d p e r c u t a n e o u s l y .
Case Report The patient was a 25-year-old white woman with a history of bladder extrophy and a subsequent ureterosigmoidostomy. She had a long history of pyelonephritis, as well as a known left lower pole calculus within a calyceal diverticulum. She was seen in the
Address reprint requests to: Jeffrey H. Reese, M.D., Veterans Administration Medical Center (112C), 3801 Miranda Avenue, Palo Alto, CA 94304, USA
emergency room 2 weeks prior to admission with left flank pain and a white blood cell count (WBC) of 13,800. An intravenous urogram (IVU) failed to reveal a significant abnormality. Despite a 2-week course of oral cinoxacin, she presented again on the day of admission with a fever of 102° F, chills, and a WBC of 23,500 with a left shift. A renal ultrasound showed a left lower pole mass and a computerized axial tomographic scan (CT) revealed a large perinephric fluid collection with apparent extension into the spleen (Fig. 1). The collection was successfully drained pereutaneously with two 12-Fr J catheters. Culture revealed gamma streptococcus. The patient was treated with 7 days of parental antibiotics followed by a 2-week course of oral antibiotics. A sinogram obtained 1 week following admission showed a persistent abscess cavity in continuitywith the lower pole renal calculus (Fig. 2). The patient was discharged with a percutaneous J tube in place. A repeat sinogram 3 weeks following initial drainage of the abscess now revealed what appeared to be a direct connection between the abscess cavity and the splenic parenchyma and splenic vein (Fig. 3). Due to the fear of erosion into the splenic vasculature, it was elected to remove the drain and observe the patient. The patient presented 6 weeks later with severe left flank pain. A repeat CT scan revealed a reaccumulation of fluid between the kidney and the spleen, and open exploration was undertaken. At the time of surgery, the kidney and spleen were noted to be densely adherent to each other with a 1 cm tract between the two organs. The renal calculus was removed via a nephrotomy, and perinephric fat was interposed between kidney and spleen to prevent recurrence. The patient had an uneventful postoperative course. A repeat CT scan (Fig. 4), obtained 5 months following surgery, revealed no evidence of recurrent abscess.
Discussion P e r i n e p h r i c abscesses are rare a n d o f t e n l i f e - t h r e a t ening infections. T h e i r incidence varies from 0.9-4 cases p e r 10,000 h o s p i t a l a d m i s s i o n s , w h e r e a s o n l y 0 . 2 % o f u r o l o g i c p r o c e d u r e s m a y be a t t r i b u t e d to this e n t i t y [3]. D u e to the w e l l - d e f i n e d b o u n d a r i e s o f G e r o t a ' s fascia, these i n f e c t i o n s are a l m o s t a l w a y s
92
J.H. Reese et al.: Perinephric Abscess
Fig. 1.
CT scan showing a large perinephric fluid collection with apparent extention into the spleen.
Fig. 2.
Sinogram showing the abscess cavity in continuity with the lower pole calculus (arrows) and the renal collecting system.
Fig. 3.
Sinogram showing contrast draining into the splenic parenchyma and splenic vein (arrows).
Fig. 4.
CT scan showing resolution of the abscess.
confined within the perinephric space. When extension occurs it does so most commonly inferiorly along the psoas muscle where the leaves of Gerota's fascia do not fuse [1]. Although rare, these abscesses may extend into the abdominal cavity or its contents. In an extensive review of the world's literature, Abeshouse [2] reported 158 cases ofperinephric infections fistulizing into the peritoneal cavity or its contents. The most common site was the colon (89 cases), whereas the next most common site was the peritoneal cavity itself (52 cases). Other abdominal sites included the stomach duodenum and uterus [2]. A large retrospective review of 117 cases of perinephric abscess from Charity Hospital in New Orleans revealed no cases of extension to visceral organs [4]. A more recent series of 71 cases of perinephric abscess en-
countered at the University of Southern California Medical Center noted one case of colonic perforation [5]. Our case represents the first reported incident o f a perinephric abscess involving the spleen. Clearly, an abscess fistulizing to the spleen represents an extraordinarily rare event. However, it does illustrate the point that virtually any organ contiguous to the kidneys may be the target for a fistula arising as a consequence of a perinephric abscess. The abscess in our patient was initially successfully treated by percutaneous drainage, although the abscess did recur 6 weeks later probably related to persistence of infection in and around the stone in the calyceal diverticulum. Unfortunately, due to its position within a calyceal diverticulum, the stone could not readily be treated by either percutaneous lithotripsy or extracorporeal shock wave lithotripsy.
93
J.H. Reese et al.: Perinephric Abscess H a d this not been the case, it is likely that percutaneous drainage would h a v e p e r m a n e n t l y cured o u r patient's abscess. In this patient, contrast m e d i a could be d e m onstrated to pass directly into the splenic parenc h y m a a n d splenic vein. O n e concern in treating this patient percutaneously was the risk o f m a s s i v e h e m o r r h a g e . H o w e v e r , no bleeding e v e r occurred. W e c a n n o t generalize f r o m a single case, b u t perc u t a n e o u s drainage o f a perinephric abscess extending into the spleen seems a reasonable option. It is d e a r l y i m p e r a t i v e that drainage o f the abscess cavity m u s t be a c c o m p a n i e d by t r e a t m e n t o f the p r i m a r y source o f infection.
References 1. Love L, Baker D, Ramsey R: Gas producing perinephric abscess. Am J Roentgenol Radium Ther Nucl Med 119:783-792, 1973. 2. Abeshouse BS: Renal and ureteral fistula of the visceral and cutaneous types: a report of four cases. Urologic Cutaneous Rev 53:641-674, 1949 3. Sheinfeld J, Erturk E, Spataro RF, Cockett AT: Perinephric abscess: current concepts. J Urol 137:191-194, 1987 4. Atcheson, DT: Perinephric abscess with a review of 117 cases. J Urol 46:201-208, 1941 5. Salvatierra O, Bucklew B, Morrow J: Perinephric abscess: a report of 71 cases. J Urol 98:296-302, 1967
