Pielonefritis enfisematosa / Emphysematous pyelonephritis

La pielonefritis enfisematosa es una enfermedad poco frecuente. Esta consiste en una infección necrotizante severa del parénquima renal asociada a formación de gas en el sistema colector, parénquima renal y/o tejidos perirrenales. Se presenta una paciente de 54 años de edad con antecedentes de diabetes mellitus tipo 2 no controlada y litiasis urinaria, atendida en el Cuerpo de Guardia del Hospital Celia Sánchez Manduley, Granma, Cuba. Presentaba náuseas y vómitos, dolor en ambos lados de la región lumbar, y fiebre. La ecografía mostró riñones hiperecogénicos e imágenes ecorefringentes en proyección de las cavidades renales. El cultivo de orina probó la presencia de escherichia coli, y se medicó de forma endovenosa. Por evolución no favorable, se realizó tomografía que evidenció patrón gaseoso en cavidades renales. Se reajustó la antibioticoterapia parenteral y la evolución fue favorable. Se dio alta de consulta, luego de 10 meses de seguimiento asintomática, con diagnóstico de pielonefritis enfisematosa(AU)

Emphysematous pyelonephritis is a rare disease, consisting of severe necrotizing infection of the renal parenchyma associated with gas formation in the collecting system, renal parenchyma and / or peri renal tissues. We report a 54-year-old patient with history of uncontrolled type 2 diabetes mellitus and urinary stones, she was treated in the emergency service at Celia Sánchez Manduley Hospital, Granma, Cuba. She had nausea and vomiting, pain on both sides of her lower back, and fever. Ultrasound showed hyper-echogenic kidneys and echo-refractive images in projection of the renal cavities. The urine culture proved the presence of Escherichia coli, and medications was administered intravenously. Due to the unfavorable evolution, a tomography was performed and it showed a gas pattern in the renal cavities. Parenteral antibiotic therapy was readjusted and the outcome was favorable. After 10 months of asymptomatic follow-up, she was discharged from the clinic with diagnosis of emphysematous pyelonephritis(AU)

Pielonefritis Enfisematosa. Reporte de dos casos / Emphysematous pyelonephritis. Report of two cases

RESUMEN La pielonefritis enfisematosa se considerada una entidad clínica inusual. Constituye una infección necrotizante aguda, con formación de gas en el parénquima renal, sistema colector y/o espacio perirrenal. La población diabética es más propensa a este tipo de pielonefritis, pero se han descrito casos de pielonefritis enfisematosa recurrente en pacientes con obstrucción de la vía urinaria en ausencia de diabetes mellitus. Del 69 al 97 % de los casos, el germen implicado en la génesis de la enfermedad es la Escherichia coli, seguido por la klebsiella pneumoniae; responsable de una enfermedad con alto impacto en la morbimortalidad de los pacientes diabéticos. El conocer esta entidad clínica, permite realizar un diagnóstico precoz con el fin de establecer el tratamiento más adecuado que contribuya a una mejor sobrevida en el paciente. Los estudios tomográficos orientan en el diagnóstico, facilitan tener la opción de un tratamiento conservador y cuando lo requiera un correcto tratamiento invasivo, que debe ser individualizado según la posible causa que lo genera (AU).

ABSTRACT Emphysematous pyelonephritis is considered an unusual clinical entity. It is an acute necrotizing infection, with gas formation in the renal parenchyma, the collector system and/or perinephric space. Diabetic population is more prone to this kind of pyelonephritis, but cases of emphysematous pyelonephritis have been described in patients with urinary tract obstruction in absence of Diabetes mellitus. On 69 to 97 % of the cases, the germ implied in the disease genesis is Escherichia coli, followed by Klebsiella pneumonia, that are responsible for a disease having a high impact on the diabetic patients´ morbidity and mortality. Knowing this clinical entity allows arriving to a precocious diagnosis with the aim of establishing the most suitable treatment contributing to a better patients´ survival. Tomographic studies guide in the diagnosis, facilitate the option of a conserving treatment, and when it is required a correct invasive treatment individualized according to the possible cause generating it (AU).

Pyelonephritis in pregnancy: clinical and laboratorial aspects and perinatal results / Pielonefrite na gestação: aspectos clínicos e laboratoriais e resultados perinatais

Abstract Objective To identify the prevalence of pyelonephritis during pregnancy and to analyze the clinical and laboratorial aspects, perinatal results and complications. Methods A transversal study of 203 pregnant women who had pyelonephritis during pregnancy and whose labor took place between 2010 and 2016 at a hospital in the state of Santa Catarina, Brazil. The analysis was based on medical records as well as on the hospital's database. Clinical and laboratory conditions, antibiotics, bacterial resistance, perinatal outcomes and complications were all taken into account. The data was compared using the Mann-Whitney test and the Chi-square test. Results A prevalence of 1.97% with pyelonephritis was evidenced, with most patients having it during the second trimester of gestation. The bacteriamost commonly found in the urine cultures was Escherichia coli, in 76.6% of cases, followed by Klebsiella pneumoniae (8.7%). Ceftriaxone had the lowest bacterial resistance (only 3.5% of the cases). On the other hand, ampicillin and cephalothin presented higher bacterial resistance, 52% and 36.2%, respectively. The risk of very premature delivery was more than 50% higher in patients with pyelonephritis. Conclusion Ampicillin and first-generation cephalosporins are associated with a higher bacterial resistance while ceftriaxone proved to have a high efficacy for the treatment of pyelonephritis due to low bacterial resistance. Patients with pyelonephritis showed a higher risk for very premature delivery (< 32 weeks). In this casuistry, there were no others significant differences in the overall perinatal outcomes when compared with the routine service series.

Resumo Objetivo Identificar a prevalência da pielonefrite durante a gestação, analisar seus aspectos clínicos e laboratoriais, resultados perinatais e complicações. Métodos Estudo transversal que incluiu 203 gestantes com pielonefrite durante a gestação e cujos partos aconteceram entre 2010 e 2016 em um hospital no estado de Santa Catarina, no Brasil. A análise foi feita através de informações coletadas de prontuários e da base de dados do hospital. Foram levados em consideração aspectos received Resultados Foi evidenciada uma prevalência de 1,97%, sendo que a maioria das pacientes se encontrava no segundo trimestre de gestação. A bactériamais encontrada nas uroculturas foi a Escherichia coli, em 76,6% dos casos, seguido pela Klebsiella pneumoniae (8,7%). A ceftriaxona, usada como primeira escolha, demonstrou ser o antibiótico commenor resistência bacteriana (apenas 3,5% dos casos). A ampicilina e a cefalotina apresentaram maiores resistências bacterianas, 52% e 36,2%, respectivamente. O risco de parto prematuro extremo (<32 semanas) foimais que 50% maior em pacientes com pielonefrite. Conclusão A ampicilina e cefalosporinas de primeira geração estão associadas à maior resistência bacteriana enquanto a ceftriaxona provou ter uma alta eficácia para o tratamento da pielonefrite devido à baixa resistência bacteriana. Pacientes com pielonefrite têm maior risco para parto prematuro extremo (< 32 semanas). Nesta casuística, não houveram outras diferenças significativas nos resultados perinatais gerais quando comparados com a série de serviços de rotina.

Evaluation of the use of DMSA in culture positive UTI and culture negative acute pyelonephritis.

This prospective study was done to assess the frequency of acute pyelonephritis (APN) in febrile children with positive urine culture as documented by Tc99m DMSA scintigraphy (DMSA) and the frequency of vesicoureteric reflux (VUR) in these children. Secondly, to determine the frequency of APN, in febrile children with supportive evidence for UTI but with negative urine culture, as documented by DMSA and frequency of VUR in them. Thirdly to stress the utility of DMSA to diagnose APN in urine culture negative febrile children and to suggest DMSA as a clinical tool in evaluation of fever of unknown origin (FUO). This study included 42 children with positive urine culture and 26 children with negative urine culture who had supportive evidence of UTI as determined by the predetermined criteria and diagnosed to have APN by DMSA. All of them had ultrasonogram (USG), DMSA and voiding cystourethrogram (VCU). They were followed up for a minimum period of 6 months. Out of the 42 children with positive urine culture 92.9% had features of APN in the DMSA of whom 82.1% had vesicoureteric relux (VUR). The DMSA was abnormal in 26 children with negative urine culture, of whom 65.4% had VUR. Ultrasound suggestive of parenchymal change was observed in 47.6% in the culture positive group and 65.4% in the culture negative group. In conclusion, it is suggested, that DMSA is a useful investigation for the diagnosis of APN in febrile UTI. DMSA is indicated in febrile children with negative urine culture but with supportive evidence of UTI and in FUO. An abnormal DMSA is a strong indication for work up for VUR.

Infección urinaria recurrente: recaida o reinfección / Recurrent urinary infection: re-infection or relapsing

La infección recurrente del tracto urinario es un síndrome que en la consulta diaria se encuantra con bastante frecuencia. Estas recurrencias de la enfermedad representan lo que se conoce como reinfeccion o recaída. Se comentan algunos mecanismos fisiopatológicos que se han asociado con este padecimiento y algunas de las posibles conductas a seguir de primera intención para su adecuado tratamiento

Epidemiología de las infecciones del tracto urinario en niños y riesgo de recurrencia y alteraciones nefrourológicas / Epidemiology of urinary tract infections in children and risk factors for recurrence and nephrourologic abnormalities

Entre marzo de 1992 y febrero de 1993, en el Servicio Salud Metropolitano Norte SSMN, se desarrolló un programa para mejorar la calidad de la atención médica y estudiar la epidemiología de las infecciones del tracto urinario (infección urinaria) en menores de 15 años. El programa incluyó la derivación de los casos sospechosos desde 7 de los 14 consultorios periféricos y la Unidad de Emergencias del servicio, a una unidad clínica habilitada en el Hospital Roberto del Río. A la fecha, la población óde 15 años del SSMN era de 188 329 habitantes, 108 221 de los cuales pertenecían a los siete consultorios adscritos al programa. Los pacientes referidos a la clínica de infección urinaria fueron estudiados y tratados en protocolos estándar y seguidos mensualmente. Se indicó ultrasonografía abdominal y uretrocistografía miccional a todos los niños con infección urinaria sin estudios previos. En 630 de los 1 275 niños referidos se confirmó la sospecha clínica de infección urinaria; la tasa de ataque de la enfermedad fue sigificativamente mayor en la población adscrita (3,7/1 000) que en la no adscrita al programa (2,7/1 000, p <0,0003). La pielonefritis aguda fue más frecuente en menores de 24 meses que en otras edades (OR= 3,3; IC 95 por ciento= 2,1-5,3); p <0,0000001). E. coli fue el microorganismo predominante en mabos sexos, pero el aislamiento de otros gérmenes fue significativamente más frecuente en varones (OR= 17,3; IC 95 por ciento= 8,0-38,0). 148 de 522 (28,4 por ciento; IC 95 por ciento= 24,5-32,3). 148 niños controlados tuvieron al menos una recurrencia de infección urinaria, 87,8 por ciento de ellas ocurrió antes del séptimo mes de seguimiento. El tramo de 48 a 71 meses de edad y los gérmenes diferentes a E. coli se asociaron a mayor riesgo de recurrir: OR= 2,5; (IC 95 por ciento= 1,5-4,0) y OR= 2,5; (IC 95 por ciento= 1,2-5,2), respectivamente. La pielonefritis aguda y el sexo masculino se asociaron a mayor riesgo de alteraciones en el estudio radiológico (OR= 2,0; IC 95 por ciento= 1,03-3,9 y OR= 2,0; IC 95 por ciento= 1,2-3,5), respectivamente

A histomorphologic and ultrastructural study of the malignant tumours of the renal pelvis.

The study was carried at two different centres. Only 9 cases of primary malignant tumours of the renal pelvis could be collected during the period of 7 years (1984-1990). Renal pelvis malignancies constituted 0.21% of all the malignancies and 12.16% of all the malignant growths of the kidney (9 out of 74 cases). The age of these patients ranged from 24 to 70 years; the mean being 41.7 years. Male/female ratio was 8:1. Common triad of complaints (pain, haematuria and lump) was noticed in 22.2% of patients. Individually they were noticed in 77.8%, 66.7% and 44.4% of patients respectively. Transitional cell carcinoma was the commonest, seen in 7 patients (77.8%) whereas squamous cell carcinoma and adenocarcinoma were noticed in one patient (11.1%) each. Hydronephrosis, chronic pyelonephritis and nephrolithiasis were noticed in 66.7%, 44.4% and 22.2% of patients respectively. Ultrastructural study of urothelial tumours revealed tumour cells in various stages of differentiation with loss of intercellular junctions and dense collection of rough endopasmic reticulum fibrils around the nucleus.