Ann Thorac Surg 1999;68:1836-1837
© 1999 The Society of Thoracic Surgeons
Case Reports
Nephrobronchial fistula secondary to xantogranulomatous pyelonephritis
Marco Alifano, MDa,
Nicolas Venissac, MDa,
Daniel Chevallier, MDb,
Jérôme Mouroux, MDa
a Service de Chirurgie Thoracique, CHU de Nice, Hôpital Pasteur, Nice, France
b Service d’Urologie, CHU de Nice, Hôpital Pasteur, Nice, France
Address reprint requests to Dr Mouroux, Service de Chirurgie Thoracique, Hôpital Pasteur, 30, Av de la Voie Romaine, BP 69, 06002 Nice Cedex 1, France
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Abstract
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We report a case of staghorn nephrolithiasis that evolved into xanthogranulomatous pyelonephritis with perinephric abscess, nephrobronchial fistula, and lung abscess. The patient was an intravenous drug abuser who tested positive for human immunodeficiency virus, without evidence of acquired immunodeficiency syndrome. He presented with a 2-month history of untreated repeated episodes of left flank pain and hyperpyrexia. Treatment involved left nephrectomy, debridement of abscess, tube drainage, and intravenous antibiotics. The patient illustrates the need to consider untreated nephrolitiasis as a predisposing factor for pulmonary complications.
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Introduction
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Xanthogranulomatous pyelonephritis is a severe chronic infection of renal parenchyma seldom encountered in clinical practice [1]. Evolution towards diffuse renal destruction is usually observed. Formation of fistulas between kidney and adjacent organs or structures is another characteristic feature [1]. We report herein a case of xanthogranulomatous pyelonephritis with perinephric abscess and nephrobronchial fistula. Such condition should be considered exceptional.
A 31-year-old white man presented with fever, cough, and mild dyspnea. An episode of massive putrid expectoration had occurred some hours before. His medical history included operation for right kidney staghorn calculus at age 20 years and for left kidney staghorn calculus 3 years later. The patient denied tobacco exposure. He was an intravenous drug abuser. Human immunodeficiency virus-1 infection had been discovered 2 years previously, but there was no acquired immunodeficiency syndrome-defining illness. On admission he referred to repeated episodes of left flank pain and hyperpyrexia in the past 2 months. He had not seen a physician concerning these symptoms. On examination he was pyretic (39.1°C) with no evident respiratory distress. He was normotensive but had a pulse rate of 120/min.
Cardiovascular and abdominal examinations were unremarkable, except for mild pain in the left lumbar area. Decreased breathing sounds and dullness to percussion were noted in the left lung base. Laboratory examinations showed anemia (hemoglobin, 6.1 mmol/L) and leukocytosis (15.1 x 109/L). Chest roentgenogram revealed a left-sided basal opacity (Fig 1). At computed tomography pelvis and calyces of left kidney were dilated and contained a staghorn calculus. An abscess of the upper portion of the kidney extending into the surrounding retroperitoneum (Fig 2) and cranially to the left lung lower lobe through the diaphragm was present. The right kidney was normal except for a small cortical cyst. Proteus mirabilis, a common urinary tract pathogen, grew from urine and sputum cultures. On the basis of these data, diagnosis of nephrobronchial fistula was established. On the basis of in vitro sensitivity tests, intravenous antibiotherapy (cefoxitin, 6 g/day) was immediately started. A week later, conservative treatment proved to be ineffective and the patient underwent operation.
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Fig 2. Computed tomogram showing the presence of an abscess in the upper portion of the left kidney extending into the surrounding retroperitoneum and cranially through the diaphragm. Thin arrow indicates the abscess; thick arrow indicates the left diaphragmatic crus.
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A conventional transperitoneal approach was used. An invasive inflammatory process spreading from the left kidney to adjacent structures was found. The presence of a large abscess extending through the diaphragm to the lung was found. Careful surgical dissection allowed us to establish that the fistolous trajectory crossed the diaphragm through the lumbocostal trigone. Nephrectomy and debridement of the abscess were performed. A 32F chest tube was inserted in the lung abscess through the lumbocostal trigone of the diaphragm; it passed transabdominally and exited through an abdominal incision. Another 32F drain was placed in the renal space. Postoperative period was uneventful. The drainage rate of both tubes rapidly decreased. On the sixth postoperative day the drains were removed as the output consisted of few milliliters of clear fluid. The patient was discharged on the eighth postoperative day. A computed tomographic scan done 1 month after the discharge showed the complete resolution of both the pulmonary and the renal space abscesses. Histologic examination of the kidney showed xantogranulomatous pyelonephritis with nephrolithiasis. Proteus mirabilis was cultured from operative specimens.
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Comment
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Nephrobronchial fistulas and lung abscess are extremely rare complications of xantogranulomatous pyelonephritis, an atypical form of renal infection, characterized by the tendency to an invasive behavior with spreading to adjacent structures and organs and formation of fistulas [1]. Gastrointestinal tract, adjacent urinary organs, and skin are the most commonly involved structures [1]. To our knowledge only 2 patients with xantogranulomatous pyelonephritis causing a pulmonary abscess have been described previously [2, 3]. On the other hand, other types of renal infection can cause nephrobronchial fistulas. Since 1900, 24 cases of nephrobronchial fistulas associated with perinephric abscess have been reported [3]. Proteus mirabilis and Escherichia coli are the most common pathogens associated with xantogranulomatous pyelonephritis [4], although the organisms involved in the two previous reports of nephrobronchial fistulas caused by xantogranulomatious pyelonephritis were Bacteroides ovatus [2] and Streptococcus viridans [3], respectively. We report a case of nephrobronchial fistula in an individual infected with the human immunodeficiency virus. Although the level of immunocompetence was not assessed, we cannot exclude that infection with the human immunodeficiency virus may be a concurrent cause of the evolution of nephrolithiasis. In the course of human immunodeficiency virus infection, there is active viral replication and progressive, albeit not constant, deterioration of immune function during clinical latency [5]. In our patient, the lack of timely medical care and recurrent episodes of flank pain and hyperpyrexia are the most likely cause of the evolution of the renal disease into xantogranulomatous pyelonephritis and abscess formation. This invasive infection spread to the thorax through the lumbocostal trigone, a portion of the diaphragm well known for its weakness. Our report confirms that untreated urinary tract lithiasis is to be considered as a predisposing factor for lung abscess. Operation (nephrectomy, if necessary, debridement of the abscess and adequate drainage) remains the cornerstone of treatment.
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References
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Parsons M.A., Harris S.C., Grainger R.G., Ross B., Smith J.A., Williams J.L. Fistula and sinus formation in xantogranulomatous pyelonephritis. A clinicopathological review and report of four cases. Br J Urol 1986;58:488-493.[Medline]
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Pandya K., Wilcox J., Khaw H., Cleveland D., Sharma O.P. Lung abscess secondary to xanthogranulomatous pyelonephritis. Thorax 1990;45:297-298.[Abstract/Free Full Text]
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O’Brien J.D., Ettinger N.A. Nephrobronchial fistula and lung abscess resulting from nephrolithiasis and pyelonephritis. Chest 1995;108:1166-1168.[Abstract/Free Full Text]
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Cohen M.S. Granulomatous nephritis. Urol Clin North Am 1986;13:647-659.[Medline]
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Pantaleo G., Graziosi C., Fauci A.S. New concepts in the immunopathogenesis of human immunodeficiency virus infection. N Engl J Med 1993;328:327-335.[Free Full Text]
Accepted for publication March 29, 1999.
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Abstract
Introduction
