A Rare Cause of Chronic Pyelonephritis: Xanthogranulomatous Pyelonephritis

Öz

Xanthogranulomatous pyelonephritis (XGP) is a chronic, destructive, granulomatous inflammation of the renal parenchyma leading non-functioning kidney. Contrast-enhanced computed tomography is the most useful diagnostic method. A 6-year-old female patient admitted to us with complaints of abdominal pain, fever, fatigue, weakness. Recurrent urinary tract infection was present in her history. The patient’s urine specimen revealed leukocyturia, hematuria, positive for nitrite and bacteria, white blood cell: 12.7x103 /microl, hemoglobin:6.2 g/dl and CRP: 101 mg/dl. In the urinary system USG imaging, the contours of the left kidney were irregular and lobulated, and medullary punctate echogenicity and calcifications were present. Contrast-enhanced abdominal computed tomography showed increased left kidney size and opacities suggestive of stone in the collecting system; pararenal area was heterogeneous. Although the patient's gentamicin treatment was completed in 7 days and meropenem treatment in 14 days, acute phase reactants did not regress. No activity uptake was observed in the left kidney lodge in renal cortical scintigraphy. Left total nephrectomy was performed with the diagnosis of non-functioning left kidney and chronic pyelonephritis. Kidney biopsy material were reported as XGP. XGP is a rare and aggressive cause of chronic pyelonephritis with serious consequences such as nephrectomy requirement.

Anahtar Kelimeler

• Chronic pyelonephritis
• Pyelonephritis
• Urinary tract infections
• Xanthogranulomatous pyelonephritis
• XGP

Kronik Piyelonefritin Nadir Bir Nedeni: Ksantogranulomatöz Piyelonefrit

Öz

Ksantogranülomatöz piyelonefrit (XGP), böbrek parankiminin fonksiyon kaybına yol açan kronik, yıkıcı, granülomatöz bir enflamasyonudur. Kontrastlı bilgisayarlı tomografi en yararlı tanı yöntemidir. Bu yazıda karın ağrısı, ateş, halsizlik şikayetleri ile başvuran ve XGP tanısı alan altı yaşında kız hastadan bahsedildi. Özgeçmişinde tekrarlayan idrar yolu enfeksiyonu öyküsü mevcuttu. İdrar incelemesinde lökositüri, hematüri, nitrit ve bakteri pozitifliği mevcuttu. Laboratuvar analizinde beyaz kan hücresi: 12,7x103 /mikrol, hemoglobin:6,2 g/dl ve CRP: 101 mg/dl saptandı. Üriner sistem ultrasonda sol böbreğin konturları düzensiz ve lobüler olup, medüller punktat ekojenite ve kalsifikasyonlar mevcuttu. Kontrastlı abdominal bilgisayarlı tomografide sol böbrek boyutunda artış ve toplayıcı sistemde taşı düşündüren opasiteler görüldü; pararenal alan heterojendi. Hastanın gentamisin tedavisi 7 güne, meropenem tedavisi 14 güne tamamlanmasına rağmen akut faz reaktanlarında gerileme olmadı. Renal kortikal sintigrafide sol böbrek lojunda aktivite tutulumu gözlenmedi. Fonksiyone olmayan sol böbrek ve kronik piyelonefrit ön tanıları ile hastaya total nefrektomi uygulandı. Böbrek biyopsi materyali XGP ile uyumlu idi. XGP, nefrektomi gereksinimi gibi ciddi sonuçları olan kronik piyelonefritin nadir ve agresif bir nedenidir. Akut faz reaktanlarında beklenen düşüş sağlanamayan ve piyürisi devam eden çocuklarda ayırıcı tanıda düşünülmelidir.

Anahtar Kelimeler

• Kronik piyelonefrit
• Piyelonefrit
• Üriner sistem enfeksiyonu
• Ksantogranulomatöz Piyelonefrit
• KGP

Kaynakça

1. Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic-pathologic review. Radiographics 2008;28:255–77; quiz 327–28.
2. Parsons MA, Harris SC, Longstaff AJ, Grainger RG. Xanthogranulomatous pyelonephritis: a pathological, clinical and aetiological analysis of 87 cases. Diagn Histopathol 1983;6:203-19.
3. Kim SW, Yoon BI, Ha US, Sohn DW, Cho YH. Xanthogranulomatous pyelonephritis: clinical experience with 21 cases. J Infect Chemother 2013;19:1221-4.
4. Titus B, Gupta S, Edpao P, Psutka SP, Limaye AP, Bakthavatsalam R, Rakita RM. Xanthogranulomatous Pyelonephritis With Direct Extension Into the Liver. Am J Med 2020;133:1054-5.
5. Wu ST. Bear paw sign: classic presentation of xanthogranulomatous pyelonephritis. QJM 2019;112:461-2.
6. Tan WP, Papagiannopoulos D, Elterman L. Bear’s Paw Sign: A Classic Presentation of Xanthogranulomatous Pyelonephritis. Urology 2015;86:e5-6.
7. Malek RS, Elder JS. Xanthogranulomatous pyelonephritis: a critical analysis of 26 cases and of the literature. J Urol 1978;119:589–93.
8. Schlagenhaufer F. Uber epigentumliche Staphylmykosen der Nieven und der pararenalen Bindegewebes. Frankfurt Z Pathol. 1916;139–148. Cited by: Korkes F, Favoretto RL, Bro´glio M, Silva CA, Castro MG, Perez MD. Xanthogranulomatous pyelonephritis: clinical experience with 41 cases. Urology 2008;71:178–80.

9. Karabulut B, Ünlüer A, Savcı G. Ksantogranulomatöz Pyelonefrit. Uludağ Üniversitesi Tıp Fakültesi Dergisi 2003;29: 69-71.
10. Caixeta EG, Matos DC, Ceranto AV, Silva JH, Barbosa CK. Xanthogranulomatous pyelonephritis in a pediatric patient. Braz J Nephrol 2022;44:452-56.
11. Kant K, Vyas MC, Pandey SK. Xanthogranulomatous pyelonephritis (report of 2 cases). J Postgrad Med 1984;30:42-5. 
12. Udare A, Abreu-Gomez J, Krishna S, McInnes M, Siegelman E, Schieda N. Imaging Manifestations of Acute and Chronic Renal Infection That Mimics Malignancy: How to Make the Diagnosis Using Computed Tomography and Magnetic Resonance Imaging. Can Assoc Radiol J 2019;70:424-33. 
13. Hartman DS, Davis CJ Jr, Goldman SM, Isbister SS, Sanders RC. Xanthogranulomatous pyelonephritis: sonographic-pathologic correlation of 16 cases. J Ultrasound Med 1984;3:481–4.
14. AlDarrab RM, AlAkrash HS, AlKhateeb SS, AlBqami NM. A case report of a xanthogranulomatous pyelonephritis case mimicking the recurrence of renal cell carcinoma after partial nephrectomy. Urol Ann 2015;7:524-6.
15. Numan L, Zamir H, Husainat NM, Tahboub M. Xanthogranulomatous Pyelonephritis Causing Renocolic Fistula Presenting as Symptomatic Anemia. Cureus 2019;11:e4947.
16. Chandanwale SS. Xanthogranulomatous Pyelonephritis: Unusual Clinical Presentation: A Case Report with Literature Review. J Family Med Prim Care 2013;2:396-8.