Perinephric Abscess

Perinephric Abscess

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A perinephric abscess is a collection of suppurative material in the perinephric space. A perinephric abscess can pose a great diagnostic challenge, even to an astute clinician. This is very important because a delay in diagnosis increases the risk of morbidity and mortality. Diagnosis of a perinephric abscess should be considered in any patient with fever and abdominal or flank pain.

The increased use of CT scanning has allowed for earlier and accurate diagnoses of this condition, and newer antibiotics have been helpful in the appropriate treatment during the last 3 decades.

A perinephric abscess is a collection of purulent material around the kidneys, with a presentation that is insidious (>14 d). This abscess formation occurs secondary to urinary tract obstruction and/or hematogenous spread from infection sites.

Perinephric abscess is an uncommon complication of urinary tract infections. The incidence ranges from 1-10 cases for every 10,000 hospital admissions. Men and women are affected with equal frequency. Patients with diabetes account for one third of all perinephric abscess cases. [1]

Escherichia coli, Proteus species, and Staphylococcus aureus are the usual etiologic organisms. The use of antibiotics for skin and wound infections also has decreased the incidence of staphylococcal infection from 45% to 6% over the last 6 decades. However, this rate has increased from 8% to 30% for E coli infections and from 4% to 44% for Proteus mirabilis infection.

Other gram-negative bacteria that can cause this infection include Klebsiella, Enterobacter, Pseudomonas, Serratia, and Citrobacterspecies.

Occasionally, the infection can occur from enterococci infection. One case caused by Streptococcus pneumoniae infection has been reported. [2] Anaerobes such as Clostridium, Bacteroides, and Actinomyces may account for some of the culture-negative abscesses.

Other causes include fungi, especially Candida species, and Mycobacterium tuberculosis. Multiple bacteria can be present in as many as 25% of cases.

Perinephric abscess secondary to Candida infection usually occurs in patients with diabetes. Predisposing factors include surgery (including renal transplantation [3] ) and prolonged antibiotic therapy.

Perinephric abscesses are located between the capsule of the kidney and the Gerota fascia. The abscesses remain confined in this location because of the Gerota fascia. Perinephric abscesses usually occur because of disruption of a corticomedullary intranephric renal abscess, recurrent pyelonephritis, xanthogranulomatous pyelonephritis, or an obstructing renal pelvic stone causing pyonephrosis. [4] Approximately 30% of cases are attributed to hematogenous dissemination of organisms from sites of infection such as wound infection, furuncles, or pulmonary infections. Abscesses can also be caused by ascending urinary tract infection.

The most common mechanism for gram-negative bacterial abscess to develop is the rupture of a corticomedullary abscess, while the most common mechanism for the development of a staphylococcal infection is the rupture of a renal cortical abscess. This finding frequently is observed in association with a previous renal operation such as a partial nephrectomy or nephrolithiasis or, most commonly, as a complication of diabetes mellitus (60-90%).

Perforation of a ureter or a calyceal fornix may rarely result in perinephric abscess formation.

Occasionally, a perinephric abscess results from the spread of infection from extraperitoneal sites, such as in retroperitoneal appendicitis, diverticulitis, pancreatitis, and pelvic inflammatory conditions. In some instances, perinephric abscess is caused by bowel perforation, Crohn disease, or osteomyelitis from the spine.

Patients with polycystic renal disease who undergo hemodialysis may be particularly susceptible to developing perinephric abscess (62% of cases).

Predisposing factors for perinephric abscess include neurogenic bladder, vesicoureteral reflux, bladder outlet obstruction, renal papillary necrosis, obstructing calculus, genitourinary tuberculosis, trauma (eg, renal biopsy, [2] urinary instrumentation, urologic surgery), immunosuppression, and intravenous drug abuse.

When a perinephric infection ruptures through the Gerota fascia into the pararenal space, it leads to the formation of a paranephric abscess. Paranephric abscesses may also be caused by infectious disorders of the intestine, pancreas, liver, gall bladder, prostate, and pleural cavity, and they may be caused by osteomyelitis of adjacent ribs or vertebrae. Sometimes, with a superimposed infection, a perirenal hematoma can progress to a perinephric abscess.

Because of nonspecific findings, in many cases, diagnosing a perinephric abscess can be difficult. Typically, patients present with a history of skin infections or urinary tract infections. An infection may be followed in 1-2 weeks by fever and unilateral flank pain. However, this is an uncommon presentation.

Typically, the onset of symptoms is insidious, and 58% of patients have symptoms for more than 14 days.

Presenting symptoms are often nonspecific. Only occasionally, a patient presents with a syndrome suggestive of acute pyelonephritis, with fever and abdominal and flank pain (usually unilateral). One distinguishing feature to note is that most patients with uncomplicated pyelonephritis are symptomatic for less than 5 days before hospitalization, whereas most patients with perinephric abscesses are symptomatic for more than 5 days.

The most common symptoms include fever (66-90%), flank or abdominal pain (40-50%), chills (40%), dysuria (40%), weight loss, lethargy, and gastrointestinal symptoms (25%). Pleuritic pain may occur due to diaphragmatic irritation. If the abscess is pressing the adjacent nerves, the referred pain may be felt in the groin, thighs, or knees.

Physical findings include flank or costovertebral tenderness. When abdominal tenderness is present (60%), it may complicate the diagnosis. Patients may present with rigidity and fullness. A flank mass is palpable if the abscess is large or located in the inferior pole of the kidney space (9-47%). A renal malignancy must be ruled out in these patients with appropriate radiographic studies (eg, CT scanning, MRI). Splinting may be present, with resultant scoliosis. Patients may experience pain upon bending toward the contralateral side, upon active flexion of the ipsilateral thigh against resistance, and upon extension of the thigh while walking. Consider the diagnosis of perinephric abscess in patients with unilateral flank pain and fever, no response to treatment for acute pyelonephritis, pyrexia of unknown origin, unexplained peritonitis, pelvic abscess, and empyema.

Promptly treat all perinephric abscesses. Failure to treat can result in severe morbidity or even death. Certain conditions, such as renal cortical abscess or enteric fistulas, may require immediate surgical intervention (see Surgical therapy). [5]

Knowledge of the retroperitoneal structures is vital in understanding the development of perinephric abscesses.

Anterior and posterior layers of renal fascia divide the retroperitoneum into 3 extraperitoneal spaces. The first, the anterior paranephric space, extends from the posterior peritoneum to the anterior renal fascia (Gerota). The second, the perinephric space, lies between 2 layers of the renal fascia. The third, the posterior paranephric space, extends from the posterior renal fascia to the fascia that lies anterior to the psoas and quadratus lumborum muscles.

The renal fascia (Gerota) surrounds the kidney and adrenal gland. Perinephric fat is present between the renal capsule and this fascia. The perinephric space also contains some blood vessels and lymphatics, which facilitate the spread of infection. The 2 layers join above the adrenal glands and are attached to the diaphragmatic fascia. They join laterally to form the lateroconal fascia that is present posterior to the colon. The anterior fascia of Zuckerkandl extends anterolaterally and then blends with the parietal peritoneum. Posteriorly, the Gerota fascia joins the quadratus lumborum fascia medially, while the anterior fascia joins the root of the mesentery and lies behind the pancreas and the duodenum.

The perinephric space becomes cone-shaped as it narrows inferiorly and medially and then joins with the iliac fascia. The inferomedial angle of the space is the weakest point, accounting for the extension of fluid collection across the midline and into the pelvis.

The only contraindication to treatment of a perinephric abscess is bleeding dyscrasias. Correct this condition prior to percutaneous drainage.

A relative contraindication is patients who are at increased anesthetic risk who require nephrectomy for treatment. Optimize these individual medical conditions prior to surgery.

Jacobson D, Gilleland J, Cameron B, Rosenbloom E. Perinephric abscesses in the pediatric population: case presentation and review of the literature. Pediatr Nephrol. 2014 May. 29 (5):919-25. [Medline].

Wickre CG, Major JL, Wolfson M. Perinephric abscess: an unusual late infectious complication of renal biopsy. Ann Clin Lab Sci. 1982 Nov-Dec. 12(6):453-4. [Medline].

Edelstein HE, McCabe RE, Lieberman E. Perinephric abscess in renal transplant recipients: report of seven cases and review. Rev Infect Dis. 1989 Jul-Aug. 11(4):569-77. [Medline].

Cheng CH, Kuo HC, Su B. Endometriosis in a kidney with focal xanthogranulomatous pyelonephritis and a perinephric abscess. BMC Res Notes. 2015 Oct 21. 8:591. [Medline].

Durant TJ, Olsen J, Bhuva V, Mogen J, Jacob J. Perinephric Abscess with Fistula Formation to Descending Colon: A Case Report and a Review of the Literature. Conn Med. 2015 Apr. 79 (4):221-4. [Medline].

Coelho RF, Schneider-Monteiro ED, Mesquita JL, Mazzucchi E, Marmo Lucon A, Srougi M. Renal and perinephric abscesses: analysis of 65 consecutive cases. World J Surg. 2007 Feb. 31(2):431-6. [Medline].

El-Nahas AR, Faisal R, Mohsen T, Al-Marhoon MS, Abol-Enein H. What is the best drainage method for a perinephric abscess?. Int Braz J Urol. 2010 Jan-Feb. 36(1):29-37. [Medline].

Alifano M, Venissac N, Chevallier D, Mouroux J. Nephrobronchial fistula secondary to xantogranulomatous pyelonephritis. Ann Thorac Surg. 1999 Nov. 68(5):1836-7. [Medline].

Baradkar VP, Mathur M, Kumar S. Renal and perinephric abscess due to Staphylococcus aureus. Indian J Pathol Microbiol. 2009 Jul-Sep. 52(3):440-1. [Medline].

Bickel A, Waxman I, Eitan A. Laparoscopic treatment of a perinephric abscess. Surg Endosc. 1995 Apr. 9(4):437-8. [Medline].

Bolkier M, Moskovitz B, Levin DR. Clinical radiological management of an uncommon perinephric abscess. Int Urol Nephrol. 1991. 23(2):117-20. [Medline].

Centers for Disease Control and Prevention (CDC). Transmission of multidrug-resistant Escherichia coli through kidney transplantation — California and Texas, 2009. MMWR Morb Mortal Wkly Rep. 2010 Dec 24. 59(50):1642-6. [Medline].

Chitnavis V, Magnussen CR. Perinephric abscess due to a coagulase-negative Staphylococcus: case report and review of the literature. J Urol. 1993 Jun. 149(6):1530-1. [Medline].

Dalla Palma L, Pozzi-Mucelli F, Ene V. Medical treatment of renal and perirenal abscesses: CT evaluation. Clin Radiol. 1999 Dec. 54(12):792-7. [Medline].

Dembry LM, Andriole VT. Renal and perirenal abscesses. Infect Dis Clin North Am. 1997 Sep. 11(3):663-80. [Medline].

Dempsey J, Scott R. Duplex Doppler examination of a perinephric abscess in a renal transplant. South Med J. 1990 Oct. 83(10):1213-5. [Medline].

Edelstein H, McCabe RE. Perinephric abscess. Modern diagnosis and treatment in 47 cases. Medicine (Baltimore). 1988 Mar. 67(2):118-31. [Medline].

El-Nahas AR, Faisal R, Mohsen T, Al-Marhoon MS, Abol-Enein H. What is the best drainage method for a perinephric abscess?. Int Braz J Urol. 2010 Jan-Feb. 36(1):29-37. [Medline].

Elyaderani MK, Moncman J. Value of ultrasonography, fine needle aspiration, and percutaneous drainage of perinephric abscesses. South Med J. 1985 Jun. 78(6):685-9. [Medline].

Fullá J, Storme O, Fica A, Varas MA, Flores J, Marchant F, et al. [Renal and perinephric abscesses: a series of 44 cases]. Rev Chilena Infectol. 2009 Oct. 26(5):445-51. [Medline].

Gardiner RA, Gwynne RA, Roberts SA. Perinephric abscess. BJU Int. April 2011. Suppl 3:20-3:[Full Text].

Gerzof SG. Percutaneous drainage of renal and perinephric abscess. Urol Radiol. 1981. 2(3):171-9. [Medline].

High KP, Quagliarello VJ. Yeast perinephric abscess: report of a case and review. Clin Infect Dis. 1992 Jul. 15(1):128-33. [Medline].

Hutchison FN, Kaysen GA. Perinephric abscess: the missed diagnosis. Med Clin North Am. 1988 Sep. 72(5):993-1014. [Medline].

Karamchandani MC, Riether R, Sheets J, Stasik J, Rosen L, Khubchandani I. Nephrocolic fistula. Dis Colon Rectum. 1986 Nov. 29(11):747-9. [Medline].

Ko MC, Liu CC, Liu CK, Woung LC, Chen HF, Su HF. Incidence of renal and perinephric abscess in diabetic patients: a population-based national study. Epidemiol Infect. 2011 Feb. 139(2):229-35. [Medline].

Lewi HJ, Scott R. Calculocutaneous sinus. Urology. 1986 Sep. 28(3):232-4. [Medline].

Lo RK, Ojeda LM, Johnson DE, Witta B. Perinephric abscess masquerading as renal tumor in an adolescent. Urology. 1984 Jan. 23(1):84-6. [Medline].

Merimsky E, Feldman C. Perinephric abscess: report of 19 cases. Int Surg. 1981 Jan-Mar. 66(1):79-80. [Medline].

Murray NW, Molavi A. Perinephric abscess: an unusual presentation of perforation of the colon. Johns Hopkins Med J. 1977 Jan. 140(1):15-8. [Medline].

Patterson JE, Andriole VT. Renal and perirenal abscesses. Infect Dis Clin North Am. 1987 Dec. 1(4):907-26. [Medline].

Pery M, Adler OB, Kaftori JK. Retroperitoneal-pericardial fistula caused by a perinephric abscess. Urol Radiol. 1990. 12(1):22-4. [Medline].

Poulos J, Johnson SR, Conrad P, Montero J, Vesely DL. Dome-shaped lesion on chest radiograph: retroperitoneal abscess dissecting through the posterior chest wall. South Med J. 1994 Jan. 87(1):77-80. [Medline].

Provet J, Gluck R, Golimbu M. Perirenal candidial abscess. Urology. 1990 Dec. 36(6):534-6. [Medline].

Reese JH, Anderson RU, Friedland G. Splenic abscess arising by direct extension from a perinephric abscess. Urol Radiol. 1990. 12(2):91-3. [Medline].

Roberts JA. Pyelonephritis, cortical abscess, and perinephric abscess. Urol Clin North Am. 1986 Nov. 13(4):637-45. [Medline].

Runyon BA. Bacterial peritonitis secondary to a perinephric abscess. Case report and differentiation from spontaneous bacterial peritonitis. Am J Med. 1986 May. 80(5):997-8. [Medline].

Shields J, Maxwell AP. Acute pyelonephritis can have serious complications. Practitioner. 2010 Apr. 254(1728):19, 21, 23-4, 2. [Medline].

Sklar AH, Caruana RJ, Lammers JE, Strauser GD. Renal infections in autosomal dominant polycystic kidney disease. Am J Kidney Dis. 1987 Aug. 10(2):81-8. [Medline].

Stewart IE, Borland C. Case report: perinephric-splenic fistula–a complication of percutaneous perinephric abscess drainage. Br J Radiol. 1994 Sep. 67(801):894-6. [Medline].

Sweet R, Keane WF. Perinephric abscess in patients with polycystic kidney disease undergoing chronic hemodialysis. Nephron. 1979. 23(5):237-40. [Medline].

Teelucksingh S, Ariyanayagam DC, Fung KF, Bartholomew C. Perinephric abscess mimicking fulminant hepatic failure. West Indian Med J. 1994 Jun. 43(2):66-7. [Medline].

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.

Jared Moss, MD Resident Physician, Division of Urology, University of Tennessee Graduate School of Medicine

Jared Moss, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus.

Daniel B Rukstalis, MD Professor of Urology, Wake Forest Baptist Health System, Wake Forest University School of Medicine

Daniel B Rukstalis, MD is a member of the following medical societies: American Association for the Advancement of Science, American Urological Association

Disclosure: Nothing to disclose.

Perinephric Abscess

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