Ann Thorac Surg 1998;65:539
© 1998 The Society of Thoracic Surgeons
Case Reports
An Unusual Cause of Hemoptysis
Beatrix E. Urbat, MD,
John R. Haapaniemi, DO,
Bruce T. Weyhing, MD,
Frank A. Baciewicz, Jr,
Cardiothoracic Surgery Division, Harper Hospital, Wayne State University, Detroit, Michigan, USA
Pulmonary Division, Grace Hospital, Wayne State University, Detroit, Michigan, USA
Radiology Department, Grace Hospital, Wayne State University, Detroit, Michigan, USA
Accepted for publication September 12, 1997.
Dr Baciewicz, 3990 John R, Suite 2102, Detroit, MI 48201 (e-mail: baciewicz@cardiology.harper.wayne.edu).
 |
Abstract
|
|---|
Xanthogranulomatous pyelonephritis is a renal inflammatory process associated with chronic obstruction and renal calculi. A patient with xanthogranulomatous pyelonephritis presented with the acute onset of hemoptysis and a lung mass. At thoracotomy the mass was resected and found to be a renal calculus embedded within inflammatory tissue.
|
Introduction
|
|---|
First described by Putschar in 1934, xanthogranulomatous pyelonephritis (XGP) is a focal or diffuse chronic renal inflammatory process seen with urinary obstruction. We present a patient with hemoptysis related to XGP.
A 70-year-old woman was admitted with a 1-day history of epistaxis and 3 days of hemoptysis. Past medical history was significant for gout, a right kidney infection drained by percutaneous tube in 1967, and an upper gastrointestinal bleed in 1987. No environmental exposures were noted. The patient had a negative response to the purified protein derivative of tuberculin test with no tuberculosis exposure history.
The patient was afebrile with decreased breath sounds and dullness to percussion at the right lung base. The abdomen was soft and nontender with fullness noted in the right upper quadrant. There was no costovertebral angle tenderness. A chest roentgenogram (Fig 1) showed a right lower lobe infiltrate. Abdominal computed tomography revealed a mass involving the right perirenal fat and right retroperitoneum (Fig 2). The mass appeared fibrofatty in character, with a central calcification. The patient underwent bronchoscopy, which was negative for an endobronchial lesion and showed only blood coming from the right lower lobe. An intravenous nephrotomogram showed a nonfunctioning right kidney, a large left kidney, and a large mass in the right retroperitoneum. Biopsy of the right retroperitoneal mass revealed dense fibrous connective tissue and mature fat, without renal parenchyma (XGP).
View larger version (139K):
[in this window]
[in a new window]
|
Abdominal computed tomographic scan reveals right-sided abdominal mass with extension to the diaphragm.
|
|
At thoracotomy, the right lower lobe was adherent to the diaphragm in the paravertebral area. A wedge resection was performed of the mass lesion in the lower lobe. The tissue was opened over the palpable mass and a staghorn calculus was removed. No purulent material was noted. The surrounding tissue was sent for frozen section, which revealed severe chronic inflammation, fibrosis, and bronchiectatic dilatation of the bronchioles with squamous metaplasia. No malignancy was identified. The urologist elected not to resect the retroperitoneal mass. The patient was discharged on the seventh postoperative day.
|
Comment
|
|---|
Xanthogranulomatous pyelonephritis is found in between 0.6% to 1.4% of patients with renal inflammation who are evaluated pathologically. Almost 70% of cases occurred in female patients, with a mean age of 50 years [1].
The etiology and pathogenesis of this disorder are unknown, but it is usually associated with chronic infection and urinary obstruction [2]. Approximately two thirds of patients have associated renal calculi, frequently of the staghorn type [1].
When the right kidney of our patient was percutaneously drained in 1967 a fistula tract was created. This tract either terminated in the retroperitoneum or perhaps transversed the diaphragm into the pleural space. The fistula tract may have allowed a renal staghorn calculus to migrate through the pleura and into the lung tissue.
In addition to the tract created by the nephrostomy tube, the fistula may have been promoted by the characteristic behavior of XGP. Adherence to adjacent tissue, necrosis, fibrosis, and foci of calcification are hallmarks of XGP. Xanthogranulomatous pyelonephritis tissue is adherent to the diaphragm and can cause perinephric abscess. Fistula tract formation to the pleura, skin, colon, and trochanteric bursa have been reported [3]. In these cases initial patient presentation has included lung abscess, draining sinus, bloody stool, and hip pyoarthrosis [4].
Most likely both the fistula tract created by prior percutaneous tube drainage of the kidney and the typical XGP behavior were responsible for the renal staghorn calculus eroding into the lung. The percutaneous drainage may have allowed the staghorn calculus into a subdiaphragmatic area or even established a path into the pleural space. The tendency of XGP to cause necrosis, along with fistula tract formation, may have provided a favorable environment for the staghorn calculus to erode into the lung.
|
References
|
|---|
- Tolia BM, Newman HR, Fuchtman, et al. Xanthogranulomatous pyelonephritis: detailed analysis of 29 cases and a brief discussion of atypical presentations. J Urol 1981;126:437-442.[Medline]
- Malek RS, Elder JS Xanthogranulomatous pyelonephritis: a critical analysis of 26 cases and of the literature. J Urol 1970;119:589-593.
- Parsons MA, Harris SC, Grainger RG, et al. Fistula and sinus formation in xanthogranulomatous pyelonephritis. Br J Urol 1986;58:488-493.[Medline]
- Pandya K, Wilcox J, Khaw H, et al. Lung abscess secondary to xanthogranulomatous pyelonephritis. Thorax 1990;45:297-299.[Abstract/Free Full Text]
Top
Abstract
Introduction
