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Proper diagnosis and treatment of renal abscess: A case report
Article in International Journal of Case Reports and Images · January 2014
DOI: 10.5348/ijcri-2014148-CR-10459
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case REPORT OPEN ACCESS
Proper diagnosis and treatment of renal abscess:
A case report
Lyh-Jyh Hao, Ray-Shyang Wang, Chien-Ta Chen, Shao-Wen Wu,
Wei-Jen Yao, Ming-Jui Wu
ABSTRACT
Introduction: Diagnosis and proper treatment of renal abscesses remain a challenge for
physicians. Reports have illustrated that small renal abscesses could be effectively treated with
a course of intravenous antibiotics. However, delay in diagnosis and treatment could lead to
higher morbidity and mortality.
Case Report: We present a 43-year-old female with a small renal abscess after incomplete
treatment of acute pyelonephritis, which was associated with renal stone and Escherichia coli
bacteremia. Patient was then treated with enough intravenous antibiotics without any classical
surgical drainage, and came out to be fully healthy.
Conclusion: This case highlights the need for early identification of risk factors as well as the
subtle feature of renal abscess by proper diagnosis and adequate treatment.
International Journal of Case Reports and Images (IJCRI)
International Journal of Case Reports and Images (IJCRI) is
an international, peer reviewed, monthly, open access, online
journal, publishing high-quality, articles in all areas of basic
medical sciences and clinical specialties.
Aim of IJCRI is to encourage the publication of new information
by providing a platform for reporting of unique, unusual and
rare cases which enhance understanding of disease process,
its diagnosis, management and clinico-pathologic correlations.
IJCRI publishes Review Articles, Case Series, Case Reports,
Case in Images, Clinical Images and Letters to Editor.
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(This page in not part of the published article.)
Int J Case Rep Images 2014;5(12):854–858. Hao et al. 854
www.ijcasereportsandimages.com
CASE REPORT OPEN ACCESS
Proper diagnosis and treatment of renal abscess:
A case report
Lyh-Jyh Hao, Ray-Shyang Wang, Chien-Ta Chen, Shao-Wen Wu,
Wei-Jen Yao, Ming-Jui Wu
Abstract the need for early identification of risk factors
as well as the subtle feature of renal abscess by
Introduction: Diagnosis and proper treatment proper diagnosis and adequate treatment.
of renal abscesses remain a challenge for
physicians. Reports have illustrated that small Keywords: Acute pyelonephritis, Antibiotics,
renal abscesses could be effectively treated Renal abscess, Renal stone
with a course of intravenous antibiotics.
However, delay in diagnosis and treatment How to cite this article
could lead to higher morbidity and mortality.
Case Report: We present a 43-year-old female Hao Lyh-Jyh, Wang Ray-Shyang, Chen Chien-Ta,
with a small renal abscess after incomplete Wu Shao-Wen, Yao Wei-Jen, Wu Ming-Jui. Proper
treatment of acute pyelonephritis, which was diagnosis and treatment of renal abscess: A case report.
associated with renal stone and Escherichia Int J Case Rep Images 2014;5(12):854–858.
coli bacteremia. Patient was then treated with
enough intravenous antibiotics without any doi:10.5348/ijcri-2014148-CR-10459
classical surgical drainage, and came out to be
fully healthy. Conclusion: This case highlights
Lyh-Jyh Hao1, Ray-Shyang Wang2, Chien-Ta Chen3, Shao- INTRODUCTION
Wen Wu4, Wei-Jen Yao5, Ming-Jui Wu1
Affiliations: 1Department of Internal Medicine, Kaohsiung Renal and perirenal abscesses are uncommon
Veteran General Hospital Tainan Branch, Tainan, Taiwan, diseases originated mainly from infections in or around
Department of Optometry, Chung Hwa University of Medical the kidney. The former one is accounted for around
and Technology, Tainan, Taiwan, Republic of China; 2Division
0.02% and the latter case is for about 0.2% of hospital
of Infection, Kaohsiung Veteran General Hospital Tainan
Branch, Tainan, Taiwan, Republic of China; 3Department admissions in Altemeier’s series of 540 intra-abdominal
of Radiology, Kaohsiung Veteran General Hospital Tainan abscesses [1]. A delay in renal abscess diagnosis may
Branch, Tainan, Taiwan, Republic of China; 4Division of lead to higher morbidity and mortality, which has been
Urology, Kaohsiung Veteran General Hospital Tainan reduced to 12% since the accessibility of computed
Branch, Tainan, Taiwan, Republic of China; 5Department tomography (CT) scan and magnetic resonance imaging
of Nuclear Medicine, College of Medicine, National Cheng- (MRI) scan [2, 3]. Classical treatment for renal abscesses
Kung University Hospital, Tainan, Taiwan, Republic of China. include surgical exploration, incision and drainage, or
Corresponding Author: Ming-Jui Wu, MD, Department of nephrectomy [4, 5]. In fact, simply invasive treatment
Internal Medicine, Kaohsiung Veteran General Hospital appeared in early 1970s, and the trend towards
Tainan Branch, Tainan, Taiwan, Republic of China; Address conservative treatment is frequent due to the progress
No: 427, Fuxing Rd., Yongkang Dist., Tainan City 710, in imaging techniques and new antibiotics. Small renal
Taiwan, Republic of China; Tel: 886-6-3125101 Ext No.
abscesses could be effectively treated with the sufficient
2317, Fax: 886-6-3123373; Email:
[email protected],
[email protected] drainage and a course of intravenous antibiotics in the
previous reports [4, 6–8]. Herein, we report a small
renal abscess after incomplete treatment of acute
Received: 25 September 2014 pyelonephritis, which was completely restored to health
Accepted: 17 October 2014 by adequate antibiotic treatment.
Published: 01 December 2014
International Journal of Case Reports and Images, Vol. 5 No. 12, December 2014. ISSN – [0976-3198]
Int J Case Rep Images 2014;5(12):854–858. Hao et al. 855
www.ijcasereportsandimages.com
CASE REPORT
A 43-year-old female, with left renal stone, presented
to our hospital after two days of fever and left flank
pain. The initial evaluation revealed high fever (body
temperature 39.7°C), tachycardia (heart rate, 112 beats
per minute), leukocytosis (white blood cell, 24,560
per micrometer) with a left shift of elevated C-reactive
protein (18.98 mg/dL), and left flank tenderness, but
no thrombocytopenia. There was no diabetes mellitus
history of this female. However, bilateral calyceal renal
stones and relative swelling of left kidney were noted
on abdomen sonography. Moreover, the blood cultures
yielded Escherichia coli and hematuria without pyuria
were noted. Thus, left side acute pyelonephritis was
impressed and intravenous antibiotics with cefazolin
1 g q8h and gentamycin 80 mg q12h were prescribed for
5 days. The patient requested discharge due to family
problem when the fever was subsided for two days with Figure 1: Sonography illustrating the 2.16 cm heterogenous
follow-up white blood cell count 11690/mm and C-reactive hypoechoic nodule in lower pole of the left kidney in the female
protein 6.11 mg/dL. patient. Area surrounded by arrowheads and yellow cross signs
indicating the renal abscess.
Oral ciprofloxacin (250 mg tablet twice per day) was
prescribed to her after discharge and she was informed
to follow-up at our outpatient department (OPD) one
week later. Unfortunately, chillness, low grade fever,
left flank pain, leukocytosis (white blood cell, 15620/
mm) and high C-reactive protein (13.39 mg/dL) recurred
three days later after discharge. She was re-admitted to
ward via OPD and followed-up abdomen sonography
showing a 2.16 cm heterogenous hypoechoic nodule
in lower pole of the left kidney, favor renal abscess
(Figure 1). After admission, medical treatment without
therapeutic drainage was suggested by infectious disease
specialist and urologist. Intravenous antibiotics with
ciprofloxacin 400 mg q12h and amikacin 250 mg q12h
were prescribed for two weeks. Fever subsided and mild
local left flank area knocking pain was noted. Normal
white blood cell count (8540/mm) and mild elevated
C-reactive protein (1.09 mg/dL) were noted. Follow-
up abdomen computed tomographic scan revealed a
1-cm abscess in lower pole of the left kidney with focal Figure 2: Follow-up abdomen computed tomography scan
revealed the 1 cm abscess in lower pole of the left kidney with
perirenal fatty blurring, indicating that partial resolution
focal perirenal fatty blurring after intravenous antibiotics with
of the left renal abscess was considered (Figure 2). She ciprofloxacin and unikin treatments for two weeks in the female
was then discharged and oral ciprofloxacin (250 mg patient. Area pointed by arrowheads indicating the reduced
tablet twice per day) was continuously prescribed for four renal abscess.
more weeks at OPD, and follow-up abdomen sonography
revealed less than 8 mm renal stone without any more
abscess (Figure 3). Extracorporeal shock wave lithotripsy
(ESWL) of left renal stone was suggested by the urologist,
but the patient refused. She was instructed to drink eight DISCUSSION
glasses of fluid daily to maintain adequate hydration
and to decrease the chance of urinary supersaturation The diagnosis of perinephric or renal abscess, as well
with stone-forming salts. Other dietary guidelines were as splenic abscess, is frequently delayed, and the mortality
suggested to avoid excessive salt and protein intake and rate in some cases is extensive. Thus, perinephric and
moderation of calcium and oxalate intake. There was no renal abscesses should be seriously taken care when a
more pyelonephritis or renal abscess recurrence of this patient presents with symptoms of pyelonephritis and
patient three years later after discharge. remains feverish after four or five days of treatment [1].
Besides, diagnoses should be entertained when a urine
International Journal of Case Reports and Images, Vol. 5 No. 12, December 2014. ISSN – [0976-3198]
Int J Case Rep Images 2014;5(12):854–858. Hao et al. 856
www.ijcasereportsandimages.com
abscesses have a higher rate of E. coli infection in urine
cultures, and a female predominance (91.8%) could be
observed [4]. This may be a result of the development of
renal abscesses via an ascending infection by organisms
already isolated within the urinary tract [7].
The intravenous antimicrobial therapy may be a good
alternative treatment if therapeutic drainage is believed
to have considerable risk. Large abscesses, obstructive
uropathy, severe vesicoureteral reflux, diabetes, old
age, and urosepsis with gas forming organisms are the
factors associated with antimicrobial treatment failure
[2]. Percutaneous nephrostomy should be considered
when there is a large abscess or obstructive uropathy,
and no clinical improvement occurs after 48 to 72
hours of appropriate antibiotic therapy [2]. An incision
and drainage is preferred when the open drainage is
Figure 3: Oral ciprofloxacin was continuously prescribed for required. Nephrectomy is reserved for patients whose
four more weeks, and follow-up abdomen sonography revealed renal parenchyma is diffusely damaged and for elderly
renal stones (less than 8 mm) without any more abscess in patients whose survival depends upon urgent surgical
lower pole of the left kidney. Pyelonephritis recurrence of the intervention [7].
patient did not occur after discharge.
Renal stone is an important risk factor for our case
and incomplete intravenous antibiotics treatment course
of acute pyelonephritis resulted in the renal abscess
culture yields a polymicrobial flora; a patient is known formation. In fact, medium-sized as well as small-sized
to have renal stones; or fever and pyuria coexist with a renal abscesses can be treated successfully with adequate
sterile urine culture. Meanwhile, renal ultrasonography IV antibiotics without surgical drainage [4]. Empirical
and abdominal CT should be exploited to confirm the therapy with broad-spectrum antibiotics (ampicillin or
authentic cause. vancomycin in combination with an aminoglycoside or
Report has suggested an algorithmic approach to third-generation cephalosporin or a fluoroquinolone) is
manage renal abscesses, which illustrated that main usually recommended because it is often very difficult to
management with antibiotics was recommended in <3 cm identify the correct causative organisms from the urine
in diameter small abscesses, and drainage (percutaneous or blood. Percutaneous drainage under CT or ultrasound
or surgical) was recommended in >5 cm large abscesses. guidance is indicated if the patient does not respond
Both approaches could be applied in medium-sized within 48 hours of treatment [6]. The drained fluid
abscesses (3–5 cm) [6]. Another report further suggested should be cultured for the causative organisms. The total
avoiding the aggressive treatment on renal and perinephric duration of the treatment was conditioned by the clinical
abscesses with 5 cm in diameter or less, which could have response and is about one to two months in most patients.
complete decrease after antibiotic therapy [9]. However, The healing of the abscess assessment criteria include
study also illustrated that aggressive drainage is suitable absence of pain, reduction of fever, normalization of
in abscesses >3 cm [6]. In fact, additional study has ESR or CRP, disappearance of the abscess on ultrasound
demonstrated that percutaneous abscess drainage might or CT scan which usually reveals a cortical scar. The
have several complications [10]. best indicator of healing is the absence of recurrence of
The total duration of antibiotic treatment course clinical signs and infection symptoms. If the clinical and
is dependent on the patient’s clinical response. The laboratory parameters come within normal limits, then
current recommendations are to continue parenteral the antibiotic treatment can be stopped 10 days later.
antimicrobial therapy for at least one to two days after The patient must be followed up over an interval of two
clinical improvement, and oral antibiotic therapy can weeks, two or three months after the end of the treatment
then be administered for an additional two weeks [11]. [14]. Asymptomatic renal stones may be followed
In previous several studies, renal stones and urinary conservatively. However, patients can be advised that
obstruction have been reported as common predisposed about 50% of small renal calculi become symptomatic
conditions with an incidence of 24–54% and 21–50% within five years [15]. Some surgical procedures may be
of renal abscess, respectively [12, 13]. More than 75% required for larger stones (i.e., ≥ 7 mm) that are unlikely
of perinephric and renal abscesses arise from a urinary to pass spontaneously. In some cases, hospitalizing a
tract infection, which ascends from the bladder to the patient with a large stone to facilitate surgical stone
kidney with pyelonephritis occurring prior to abscess intervention is reasonable. However, acute renal colic
development [1]. E. coli, Proteus spp., and Klebsiella mostly can be treated on an ambulatory care [16]. General
spp. are the organisms most frequently encountered in treatment of renal stones is with hydration to increase
perinephric and renal abscesses [1]. Patients with renal urine output and with analgesia. Renal calculi less than
International Journal of Case Reports and Images, Vol. 5 No. 12, December 2014. ISSN – [0976-3198]
Int J Case Rep Images 2014;5(12):854–858. Hao et al. 857
www.ijcasereportsandimages.com
2 cm in size can generally be treated with extra corporeal License which permits unrestricted use, distribution
shock wave lithotripsy (ESWL) [17]. After passage of the and reproduction in any medium provided the original
stones, treatment is directed at prevention of recurrent author(s) and original publisher are properly credited.
stones formation. The foundation of renal stones therapy Please see the copyright policy on the journal website for
is maintenance of high urine output (2–3 L/day) with more information.
oral hydration and a low-salt diet (<2 g/day) [18].
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