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MODEL
Kaohsiung Journal of Medical Sciences (2014) xx, 1e2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.kjms-online.com
LETTER TO THE EDITOR
Ureteral calculi combined with xanthogranulomatous pyelonephritis mimicking renal tuberculosis in a male child To the Editor, Xanthogranulomatous pyelonephritis (XGP) is a severe, uncommon form of chronic inflammatory renal parenchymal infection, and it accounts for 0.6% of cases of histologically confirmed chronic pyelonephritis [1]. Xanthogranulomatous pyelonephritis occurs at any age, but is more common among females, particularly middle-aged women [2]. Hendrickson et al. [3] report that it is very rare in children. A 14-year-old boy presented with a 6-month history of right flank pain, frequent urination, and intermittent hematuria and pyuria. At another hospital, he had previously been diagnosed as having right ureteral calculi and renal tuberculosis (TB). He was then treated with oral antiinflammatory and anti-TB drugs (e.g., isoniazid, rifampicin, and pyrazinamide). His condition gradually improved after 4 weeks. However, he subsequently presented to our institution with hematuria and pyuria that had been progressively worsening for 2 days. On examination, he had a low-grade fever (37.5 C). Blood analysis revealed an elevated leukocyte count (11.2 109/L) and a decreased hemoglobin level (95 g/L). Urinalysis showed hematuria and the presence of leukocytes (24 cells per high-powered field). A urine culture showed a bacterial count of >10,000/mL and an erythrocyte sedimentation rate (ESR) of 24 mm/hour. Purified protein derivative (PPD) testing and acid-fast staining of urinary sediment yielded positive results. Ultrasonography and computed tomography (CT) showed right ureteral calculi combined with renal TB (Fig. 1A). Single-photon emission CT indicated a nonfunctioning right kidney. The right kidney and right upper ureter were resected and a taupe-colored stone was detected. Postoperative
pathological examination indicated kidney damage with the aggregation of many foamy histiocytes, lymphocytes, and plasma cells (Fig. 1B). Immunohistochemical examination indicated CD68 positivity and foam cell PCK negativity (Fig. 1C and D). Polymerase chain reaction (PCR) yielded negative results for tuberculoid DNA. We concluded that the findings do not suggest renal TB, but do support a diagnosis of XGP. The patient was discharged 1 week postoperatively. Preoperative diagnosis of XGP is complicated by nonspecific clinical and imaging features and by laboratory findings; it is confirmed by histopathology [4]. XGP is frequently misdiagnosed preoperatively as inflammatory or neoplastic renal diseases [1e5]. In our patient, flank pain, frequent urination, hematuria and pyuria, increased ESR, PPD-positive test results, positive acid-fast stain for urinary sediment, radiologic features, and gradual improvement after diagnostic drug therapy led to the misdiagnosis of renal TB. However, the improvement in the patient after undergoing anti-inflammatory and anti-TB treatment may have resulted from the presence of a mixed infection. A PPDpositive test result may have been caused by TB vaccination the patient received after birth. The positive result for acid-fast staining of urinary sediment may indicate infection by Mycobacterium smegmatis or other acid-fast bacillus rather than by Mycobacterium tuberculosis. Intermittent hematuria and pyuria may have been caused by urinary tract obstruction that prevented contaminated urine from reaching the bladder or antibiotic treatment administered prior to admission. Surgery, including nephrectomy, is recommended for treating XGP. A good prognosis can be achieved after surgical resection [5]. In this paper, we performed open nephroureterectomy, and
Conflicts of interest: There are no competing financial interests to report. http://dx.doi.org/10.1016/j.kjms.2014.02.005 1607-551X/Copyright ª 2014, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Cao D, et al., Ureteral calculi combined with xanthogranulomatous pyelonephritis mimicking renal tuberculosis in a male child, Kaohsiung Journal of Medical Sciences (2014), http://dx.doi.org/10.1016/j.kjms.2014.02.005
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Letter to the Editor
Figure 1. (A) Computed tomography (CT) scan shows a high-density plot area of 0.9 cm 1.3 cm 1.8 cm in the right urinary tract. The right renal pelvis and calyces show marked dilation and fluid accumulation. Multiple low-density lesions are aggregated in the shape of flower petals. (B) Histological features of the resected kidney show a mixed inflammatory infiltrate with foamy macrophages, lymphoplasmacytic inflammation, and scattered giant cells (HE staining; original magnification, 40). (C) Positive results for CD68 (immunohistochemical staining; original magnification, 40). (D) Negative results for foam cell PCK (immunohistochemical staining; original magnification, 40).
the patient had a stable recovery without any relapse during 3 years of follow up.
References [1] Malek RS, Greene LF, DeWeerd JH, Farrow GM. Xanthogranulomatous pyelonephritis. Br J Urol 1972;44:296e308. [2] Li L, Parwani AV. Xanthogranulomatous pyelonephritis. Arch Pathol Lab Med 2011;135:671e4. [3] Hendrickson RJ, Lutfiyya WL, Karrer FM, Furness 3rd PD, Mengshol S, Bensard DD. Xanthogranulomatous pyelonephritis. J Pediatr Surg 2006;41:e15e7. [4] Inouye BM, Chiang G, Newbury RO, Holmes N. Adolescent xanthogranulomatous pyelonephritis mimicking renal cell carcinoma on urine cytology: an atypical presentation. Urology 2013;81:885e7.
[5] Singh R, Gupta G, Kumar P, Kotasthane DS. Xanthogranulomatous pyelonephritis in a male childda case report with a brief review of literature. J Indian Med Assoc 2012;110:739e40.
Dehong Cao Liangren Liu Liang Gao Qiang Wei* Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China *Corresponding author. Department of Urology, West China Hospital, Sichuan University, Number 37, Guoxue Alley, Chengdu, Sichuan, People’s Republic of China. E-mail address: [email protected] (Q. Wei)
Please cite this article in press as: Cao D, et al., Ureteral calculi combined with xanthogranulomatous pyelonephritis mimicking renal tuberculosis in a male child, Kaohsiung Journal of Medical Sciences (2014), http://dx.doi.org/10.1016/j.kjms.2014.02.005
MODEL
Kaohsiung Journal of Medical Sciences (2014) xx, 1e2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.kjms-online.com
LETTER TO THE EDITOR
Ureteral calculi combined with xanthogranulomatous pyelonephritis mimicking renal tuberculosis in a male child To the Editor, Xanthogranulomatous pyelonephritis (XGP) is a severe, uncommon form of chronic inflammatory renal parenchymal infection, and it accounts for 0.6% of cases of histologically confirmed chronic pyelonephritis [1]. Xanthogranulomatous pyelonephritis occurs at any age, but is more common among females, particularly middle-aged women [2]. Hendrickson et al. [3] report that it is very rare in children. A 14-year-old boy presented with a 6-month history of right flank pain, frequent urination, and intermittent hematuria and pyuria. At another hospital, he had previously been diagnosed as having right ureteral calculi and renal tuberculosis (TB). He was then treated with oral antiinflammatory and anti-TB drugs (e.g., isoniazid, rifampicin, and pyrazinamide). His condition gradually improved after 4 weeks. However, he subsequently presented to our institution with hematuria and pyuria that had been progressively worsening for 2 days. On examination, he had a low-grade fever (37.5 C). Blood analysis revealed an elevated leukocyte count (11.2 109/L) and a decreased hemoglobin level (95 g/L). Urinalysis showed hematuria and the presence of leukocytes (24 cells per high-powered field). A urine culture showed a bacterial count of >10,000/mL and an erythrocyte sedimentation rate (ESR) of 24 mm/hour. Purified protein derivative (PPD) testing and acid-fast staining of urinary sediment yielded positive results. Ultrasonography and computed tomography (CT) showed right ureteral calculi combined with renal TB (Fig. 1A). Single-photon emission CT indicated a nonfunctioning right kidney. The right kidney and right upper ureter were resected and a taupe-colored stone was detected. Postoperative
pathological examination indicated kidney damage with the aggregation of many foamy histiocytes, lymphocytes, and plasma cells (Fig. 1B). Immunohistochemical examination indicated CD68 positivity and foam cell PCK negativity (Fig. 1C and D). Polymerase chain reaction (PCR) yielded negative results for tuberculoid DNA. We concluded that the findings do not suggest renal TB, but do support a diagnosis of XGP. The patient was discharged 1 week postoperatively. Preoperative diagnosis of XGP is complicated by nonspecific clinical and imaging features and by laboratory findings; it is confirmed by histopathology [4]. XGP is frequently misdiagnosed preoperatively as inflammatory or neoplastic renal diseases [1e5]. In our patient, flank pain, frequent urination, hematuria and pyuria, increased ESR, PPD-positive test results, positive acid-fast stain for urinary sediment, radiologic features, and gradual improvement after diagnostic drug therapy led to the misdiagnosis of renal TB. However, the improvement in the patient after undergoing anti-inflammatory and anti-TB treatment may have resulted from the presence of a mixed infection. A PPDpositive test result may have been caused by TB vaccination the patient received after birth. The positive result for acid-fast staining of urinary sediment may indicate infection by Mycobacterium smegmatis or other acid-fast bacillus rather than by Mycobacterium tuberculosis. Intermittent hematuria and pyuria may have been caused by urinary tract obstruction that prevented contaminated urine from reaching the bladder or antibiotic treatment administered prior to admission. Surgery, including nephrectomy, is recommended for treating XGP. A good prognosis can be achieved after surgical resection [5]. In this paper, we performed open nephroureterectomy, and
Conflicts of interest: There are no competing financial interests to report. http://dx.doi.org/10.1016/j.kjms.2014.02.005 1607-551X/Copyright ª 2014, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Cao D, et al., Ureteral calculi combined with xanthogranulomatous pyelonephritis mimicking renal tuberculosis in a male child, Kaohsiung Journal of Medical Sciences (2014), http://dx.doi.org/10.1016/j.kjms.2014.02.005
+
MODEL
2
Letter to the Editor
Figure 1. (A) Computed tomography (CT) scan shows a high-density plot area of 0.9 cm 1.3 cm 1.8 cm in the right urinary tract. The right renal pelvis and calyces show marked dilation and fluid accumulation. Multiple low-density lesions are aggregated in the shape of flower petals. (B) Histological features of the resected kidney show a mixed inflammatory infiltrate with foamy macrophages, lymphoplasmacytic inflammation, and scattered giant cells (HE staining; original magnification, 40). (C) Positive results for CD68 (immunohistochemical staining; original magnification, 40). (D) Negative results for foam cell PCK (immunohistochemical staining; original magnification, 40).
the patient had a stable recovery without any relapse during 3 years of follow up.
References [1] Malek RS, Greene LF, DeWeerd JH, Farrow GM. Xanthogranulomatous pyelonephritis. Br J Urol 1972;44:296e308. [2] Li L, Parwani AV. Xanthogranulomatous pyelonephritis. Arch Pathol Lab Med 2011;135:671e4. [3] Hendrickson RJ, Lutfiyya WL, Karrer FM, Furness 3rd PD, Mengshol S, Bensard DD. Xanthogranulomatous pyelonephritis. J Pediatr Surg 2006;41:e15e7. [4] Inouye BM, Chiang G, Newbury RO, Holmes N. Adolescent xanthogranulomatous pyelonephritis mimicking renal cell carcinoma on urine cytology: an atypical presentation. Urology 2013;81:885e7.
[5] Singh R, Gupta G, Kumar P, Kotasthane DS. Xanthogranulomatous pyelonephritis in a male childda case report with a brief review of literature. J Indian Med Assoc 2012;110:739e40.
Dehong Cao Liangren Liu Liang Gao Qiang Wei* Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China *Corresponding author. Department of Urology, West China Hospital, Sichuan University, Number 37, Guoxue Alley, Chengdu, Sichuan, People’s Republic of China. E-mail address: [email protected] (Q. Wei)
Please cite this article in press as: Cao D, et al., Ureteral calculi combined with xanthogranulomatous pyelonephritis mimicking renal tuberculosis in a male child, Kaohsiung Journal of Medical Sciences (2014), http://dx.doi.org/10.1016/j.kjms.2014.02.005
