IMAGING RENAL INFECTION

Dr Aditi Veeratterapillay
Consultant Radiologist
 Overview
• Pathogenesis of urinary tract infections

• Pyelonephritis

• Renal and perinephric abscess

• Emphysematous pyelonephritis

• Xanthogranulomatous pyelonephritis

• TB
 Types of PYELONEPHRITIS
• ACUTE UNCOMPLICATED

• ACUTE COMPLICATED

• CHRONIC

• EMPHYSEMATOUS PYELONEPHRITIS

• XANTHOGRANULOMATOUS PYELONEPHRITIS
 INDICATIONS FOR IMAGING
• DIABETIC PATIENTS
• IMMUNOCOMPROMISED PATIENTS
• HISTORY OF UROLITHIASIS
• KNOWN CASE OF RENAL ANOMALY
• RECENT UROLOGICAL PROCEDURE
• PERSISTENCE OF LEUKOCYTOSIS AND FEVER 72 HRS AFTER
ANTIBIOTIC TREATMENT
Options for Imaging
• Computed tomography (CT) of the abdomen and pelvis with
contrast is considered the study of choice. Detects focal
parenchymal abnormalities, anatomic anomalies,
emphysematous changes, cause of ureteric obstruction perinephric
fluid collections and abscesses that necessitate a change in
management

• CT Urogram technique
3 phases
Non-contrast phase
Nephrographic phase scanned at 80 to 120 s delay
Excretory phase scanned at 10–15 min delay.
Ultrasonography is most helpful in detecting hydronephrosis ,
pyonephrosis and perinehric collection. Advantages are
relatively low cost, easily available portability, and the lack of
radiation and contrast exposure

MRI
• more costly
• time-consuming compared to CT
• MRI is nevertheless the imaging study of choice if
iodinated contrast or ionizing radiation must be avoided
and in pregnancy.
Steinstrasse (German for
'stone street'), refers to
multiple small ureteric
stones, seen aligned in
the right ureter, that
occur as a complication
of ESWL.
ULTRASOUND
• ENLARGED KIDNEY
• HYPOECHOIC
• REDUCED FLOW TO THE AREA ON DOPPLER
• HYDRONEPHROSIS
• HYDROURETER - CALCULUS AT UVJ EASILY DETECTED
• RENAL AND PERINEPHRIC ABSCESS – IMPORTANT ROLE OF
RADIOLOGIST IN USG / CT GUIDED ASPIRATION
CT Features of PYONEPHROSIS

Dilatation and obstruction of the collecting system

Thickening of renal pelvic wall > 2 mm.
Higher than usual attenuation values of the fluid within the renal
collecting system
Gas-fluid levels in the intrarenal collecting system
• Clinical features of acute infection along with hydronephrosis is the
most sensitive indicator of pyonephrosis.
Pyonephrosis
• Presence of pus within the upper collecting system
• Obstruction to the urinary tract common cause
• USG shows debris in the collecting system or a fluid fluid level .
Acute PYELONEPHRITIS CT
AREA OF REDUCED ENHANCEMENT AND STRIATED NEPHROGRAM
RENAL INFARCTION

Cortical rim sign

Differentiate from
pyelonephritis
RENAL AND PERINEPHRIC ABSCESS
EMPHYSEMATOUS PYELONEPHRITIS
• Emphysematous pyelonephritis (EPN) is an acute severe
necrotizing infection of the renal parenchyma and its
surrounding tissues that results in the presence of gas in the
renal parenchyma, collecting system, or perinephric space

• Escherichia coli. Other bacteria include Klebsiella pneumoniae,

Proteus mirabilis and Pseudomonas aeruginosa

• Life threatening complication of bacterial pyelonephritis may

rapidly progress to septic shock. Patients are extremely ill and
should be treated promptly
CT features of emphysematous pyelonephritis can be
differentiated into two types :
•Type 1
• greater than one-third renal parenchymal destruction
• streaky or mottled appearance of gas

•Type 2
• destruction of less than one-third of the parenchyma
INDIAN JOURNALOF ENDOCRINOLOGY AND METABOLISM JULY –
AUGUST 2016

Emphysematous pyelonephritis: A 10-year experience with 26 cases

CONCLUSIONS OF STUDY
• ALL DM PATIENTS
• E COLI MOST FREQUENT PATHOGEN
• NEARLY ALL WOMEN
• CONSERVATIVE TREATMENT HAD A GOOD SUCCESS RATE 88.5 %
• CONSIDER NEPHRECTOMY ONLY IN PATIENTS WHO DETERIORATE OR
NO RESPONSE TO MEDICAL TREATMENT.
Emphysematous pyelitis

Emphysematous pyelitis
is isolated gas production
inside the excretory
system, secondary to
acute bacterial infection.
It is a relatively benign
entity and needs accurate
differentiation from the
far more serious
emphysematous
pyelonephritis.
Emphysematous pyelitis and Cystitis
EPN MIMIC
Xanthogranulomatous pyelonephritis
• First described by Schlagenhaufer in 1916, 0.6% of chronic
pyelonephritis cases
• Xanthogranulomatous pyelonephritis is an uncommon chronic
destructive granulomatous process of renal parenchyma in association
with long-term urinary tract obstruction and infection.
• Usually secondary to staghorn calculus ( 70% ) and caused by Proteus
or E.coli
• Focal form or diffuse
• CT scan finding of ‘Bear paw ’ sign
• Histopathology shows Lipid laden foamy macrophage
• Treatment : Nephrectomy
•US: renal enlargement with pelvicalyceal dilatation,
parenchymal destruction and multiple anechoic areas with
hyperechogenic septa.

•CT: multiloculated appearance (low density rounded areas

throughout the enlarged left kidney): bear’s paw sign.
 MRI

Hyperintense (or
isointense) appearance of
the solid component and
hypointense cavity fluid
on T1-weighted images.
The administration of
contrast material can
reveal strong rim
enhancement of the
borders.
• 52 studies (868 patients) over last 20 years included
• 99.8% of patients underwent nephrectomy
Tuberculosis characteristics
• Hematogenous spread from a primary focus
• Granuloma formation
• Caseous necrosis
• Cavitation
• Fibrosis
• Calcium deposition
• Strictures formation which leads to chronic obstruction and renal
dysfunction
 RENAL TUBERCULOSIS
Early
• Papillary necrosis (single or multiple) resulting in uneven caliectasis 

Progressive

• Multifocal strictures can affect any part of the collecting system

• Hydronephrosis
• Mural thickening and enhancement of ureter
End-stage

• Progressive hydronephrosis results in very thin parenchyma, scarring of cortex

• Dystrophic calcification eventually involves the entire kidney (known as 

putty kidney)
Beaded ureter due to
strictures
Thimble bladder- term for
extreme fibrosis and
contracture of bladder​
walls, resulting in a tiny
bladder.
MALAKOPLAKIA : Rare chronic inflammatory / granulomatous
disease that most commonly affects genitourinary tract
Patho physiology
• Usually associated with infection due to gram negative bacteria esp E.coli and
immunosuppression

• Due to macrophage dysfunction

• Basophilic intracytoplasmic inclusions in macrophages termed

Michaelis-Gutmann  bodies

• Symptoms consist of hematuria, dysuria , recurrent UTI

• Cystoscopy and biopsy

Fungal Infection
• Fungal infection of the urinary tract is a severe life threatening
infection particularly affecting patients with diabetes mellitus,
haematological malignancy, HIV or other immunocompromised
status.
• Candida and Aspergillus and Mycor
Multiple small hypoattenuating lesions and
Fungal bezoar in right renal pelvis
RARE COMPLICATIONS
SEPTIC EMBOLI - embolization of infectious particles into lungs via
pulmonary arteries
RENAL VEIN THROMBOSIS
MRI T2, T2 FATSAT
 Conclusions
• Imaging (USS/CT) essential to rule out obstructive pyelonephritis

• Imaging differentiation of emphysematous and xanthogranulomatous

pyelonephritis may be difficult

• Radiological manifestation of urinary TB wideranging

• To consider rare type of infection in DM, immunocompromised patients