Nephrobronchial fistula a case report and review of the literature

Pyelo-hepatic abscess caused by staghorn stone infection: a case report

BACKGROUND

The most common source of pyogenic liver abscess is biliary tract infection. Other less common routes include the spread of bacteria from distant foci. However, direct extension of a perinephric infection focus to the liver is extremely rare.

CASE REPORT

The patient was a non-diabetic, immunocompetent, 29-year-old woman of mixed race ancestry with a history of recurrent urinary tract infections who was referred to our hospital because of an ultrasound-detected liver abscess. She was initially treated with metronidazole for 20 days at the referring institution for suspected amebic abscess without improvement. On admission to our center, she was febrile and complained of a dull right upper quadrant pain. A POCUS ultrasound suggested a pyogenic abscess, probably from a staghorn calculus infection. She received meroperem and amikacin for 22 and 10 days, respectively. Repeat hemocultures showed no growth, but urine cultures were positive for Proteus sp. Complete remission of clinical and imaging findings was observed under antibiotics. The patient was referred to the urology outpatient clinic to discuss the option of radical nephrectomy. CONCLUSION : This case underlines the high morbidity of staghorn calculi.

Case Series of MRI and CT Assessment of Acquired Hepato-Biliary and Pancreatic Transdiaphragmatic Fistulae

Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.

MDCT Diagnosis and Staging of Xanthogranulomatous Pyelonephritis

Background: Benign nephrectomy to treat patients with renal inflammatory disease in cases of severe urinary infection represents a diagnostic and management challenge because of significant inflammatory, fibrotic, and infectious components. Among renal inflammatory diseases, fistulization and invasiveness to adjacent structures are some of the hallmarks of xanthogranulomatous pyelonephritis (XGP). The aims of this study were as follows 1. to retrospectively determine key demographic and clinical features of XGP among benign nephrectomies; 2. to assess the CT preoperative diagnostic accuracy; and 3. to define the imaging characteristics of the CT stage. Material and Methods: A retrospective review of clinical, laboratory, and radiological features and operative methods of patients who underwent benign nephrectomy with histologically proven XGP was performed. Results: XPG was diagnosed in 18 patients over a 4-year (2018–2022) period. XGP represented 43.90% among benign nephrectomies. The mean age of the patients was 63 years, and the sex prevalence was higher in women (72.22%). Symptoms were vague and not specifically referrable to urinary tract disorders and unilateral (100%), with the left kidney affected in 61.11% of cases. Staghorn calculi and stone disease were the most common underlying cause (72.22%). All patients underwent CT. The preoperative CT imaging accuracy for renal inflammatory disease was 94.44% and indeterminate in 5.56%. A suspected diagnosis of XGP was formulated in 66.67% (12/18; 2 stage II/10 stage III), meanwhile, in 33.33% (6 patients with stage I), a non-specific diagnosis of renal inflammatory disease was formulated. CT was reported according to the Malek and Elder classification and staged in the stage I nephric form (33.33%), stage II perinephric form (11.11%), stage III paranephric form (55.56%). Conclusions: The CT diagnostic accuracy for kidney inflammatory disease was extremely high, whereas the suspected diagnosis of XGP was formulated preoperatively in only 66.67% of high-stage disease, where the hallmarks of invasiveness and fistulization of the pathology increased the diagnostic confidence.

Nephrolithiasis as a cause of hemoptysis

We report a case of nephrobronchial fistula complicated by the development of a broncholith within the lung, which led to hemoptysis and blood loss anemia. A 71-year-old man with a medical history of untreated urinary stones was admitted for flank pain, hemoptysis, blood loss anemia, and exacerbation of chronic pyelonephritis. Computed tomography showed staghorn calculi, terminal hydronephrosis, xanthogranulomatous pyelonephritis of the left kidney, nephrobronchial fistula, and large intraparenchymal pulmonary calcification. Surgical treatment was performed in two steps: nephrectomy and then left lower lobectomy. Pathological findings were suggestive of chronic inflammatory changes.

A case of xanthogranulomatous pyelonephritis leading to nephrobronchial fistula and lung abscess: does it always manifest with respiratory symptoms?

Xanthogranulomatous pyelonephritis (XGP) is a serious manifestation of chronic kidney inflammation that can expand to adjacent structures. Here we report a case of XGP extending beyond the diaphragm through a nephrobronchial fistula to form a lung abscess in a 70-year-old man. The patient presented to the emergency department with severe right flank colic pain, nausea, vomiting and nonspecific constitutional symptoms for the past 4 months. Although the patient did not complain of any respiratory symptoms, initial evaluations revealed severe right-sided hydroureteronephrosis with debris, as well as an area of infiltration in the right lung lower lobe (RLL). Given the patient's condition, a thorough work-up was expedited to investigate the potential association between the symptoms. Ultimately, a diagnosis of XGP with expansion to the RLL through the right hemidiaphragm was developed. A right radical nephrectomy, right lower lobectomy and right hemidiaphragm resection were carried out. XGP was confirmed on the basis of the pathological evaluation of the resected specimens.

“Uroptysis!” – A case report of xanthogranulomatous pyelonephritis with nephrobronchial fistulation

Introduction and importance

Xanthogranulomatous pyelonephritis (XGP) is an uncommon complication of chronic urinary tract infection, classically secondary to a chronic obstructive uropathy, resulting in destruction of renal parenchyma and a non-functioning kidney (Jha and Aeddula, 2022 [1]). This is rarely associated with nephrobronchial fistulation, with few published case reports in the literature to date.

Case presentation

We present the rare case of a 42-year-old female who was admitted to an Irish tertiary urology centre with abdominal pain, elevated inflammatory markers and an obstructive uropathy on initial imaging, with a new diagnosis of XGP. Initial management was with targeted intravenous antimicrobial therapy, percutaneous nephrostomy and perinephric drain insertion. The subsequent discovery of a nephrobronchial fistula later complicated the case, warranting plan for interval nephrectomy and fistula repair following prolonged medical management. We discuss the initial presentation, workup and image-guided approach to management.

Clinical discussion

XGP is an uncommon sequela of chronic renal suppurative infection, and is usually associated with long-standing ureteric obstruction secondary to a staghorn calculus. Nephrobronchial fistulation is a rare complication of XGP, highlighting the significance of this case discussion.

Conclusion

XGP should be considered in cases of suspected chronic pyelonephritis and may rarely lead to nephrobronchial fistulation. In cases of known XGP and pleural empyema, nephrobronchial fistulation should be considered as part of the differential diagnosis.

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Xanthogranulomatous pyelonephritis is rare and associated with chronic upper urinary tract infection and obstruction.

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Nephrobronchial fistulation is a rare complication of xanthogranulomatous pyelonephritis.

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In cases of XGP and concurrent pleural empyema, a nephrobronchial fistula should be considered.