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517

CT and Sonography
Severe
Renal and
Infections

William

Hoddick1

R. Brooke
Jeffrey12
Henry
I. Goldberg1
Michael

P. Federle12

Faye

C. Laing12

Twelve patients with urosepsis

and severe renal or perirenal
infections
were evaluated with both computed
tomography
(CT) and sonography.
Six patients
had nine
proven renal or perirenal
abscesses
larger than 2 cm in diameter.
One patient
had
multiple
microabscesses
smaller
than 1 cm. Five patients
had CT or sonographic
evidence
of focal or multifocal
bacterial
nephritis.
Computed
tomography
correctly
diagnosed
all renal (six) and perirenal
(three)
abscesses.
Sonography
was falsely
negative
in a patient with multiple microabscesses
and in another patient with a gasforming perinephric
abscess.
In one patient with four bilateral
renal abscesses,
sonography correctly
diagnosed
only one of the abscesses.
In the five patients with focal
or multifocal
bacterial
nephritis,
CT demonstrated
poorly defined,
poorly enhancing
lesions in all cases. Sonography
was normal in three of these patients.
Although
this
report is based on a limited experience,
computed
tomography
seems to be the more
sensitive method of evaluating
severe renal and perirenal
infections.

Acute
pyelonephnitis
pniate antibiotic
therapy.

in most adult
patients
In patients
unresponsive

radiologic

is warranted

renal

investigation

abscess.

the primary

Most

Until

recently

methods

used

usefulness

of CT and

however,

in evaluating

methods

in

sonographic

renal

patients

During

Department
nia,

San

18, 1 982:

of Radiology,

Francisco,

accepted
University

October
of Califor-

CA 94143.

of Radiology,
1001 Potrero

San Francisco
General Hospital,
Ave., San Francisco,
CA 94110. Address reprintrequests to R. B. Jeffrey.
AJR 140:517-520, March 1983
0361 -8o3x/83/1
403-0517
$00.00
American
Roentgen
Ray Society

with

in 1 2 such

possible

with

obstruction

angiography

suspected

or a

have

renal

been

abscesses.

both

renal

comparisons

renal

abscesses.

patients

and

review

and

penirenal

between
We
the

infections

the two imaging

report

the

noninvasive

CT

and

imaging

of

and Methods
the

period

between

January

1 979

and

March

1 982,

1 2 patients

were

evaluated

with both CT and sonography

a similar clinical presentation

for possible
renal abscesses.
Eleven of the 1 2 patients
had
with an initial diagnosis
of acute pyelonephnitis
(fever, flank

pain,

tract

and

therapy.
mia.

2Department

in evaluating

findings

ureteral

and

after appromanagement,

pyelonephnitis
will have normal excretory
urograms,
such as a renal mass, comhave largely supplanted
angiognaphy
as
Several
reports
have documented
the

have been few direct

patients

either

promptly
medical

infections.

Subjects

August

sonography

there

resolve
to initial

urognaphy

patients

[2-7];

will

to exclude

excretory

with uncomplicated
acute
urograms
[1 ]. In patients
with abnormal
puted tomography
(CT) and sonography
the next imaging
method
of choice.

Received
19, 1982.

of
Perirenal

patients

The

documented

urinary

One patient

developed

age
were

range

of

the

infection)

systemic

patients

was

and

a poor

candidiasis
1 0-73

years

response

after

to appropriate

chemotherapy

(mean,

47

years).

antibiotic

for acute
Five

leuke-

of the

12

diabetic.

Both the CT and sonographic

examinations
were performed
within a 48-hr period.
In
most cases sonography
was performed
initially
and the results were known before CT.
Only three patients
had excretory
urography
before CT and sonography.
Sonography
was
performed
with a commercially
available
digital
gray-scale
scanner
using a 3.5 MHz
transducer.
Real-time
examination
was performed
in all patients
using a 3.5 MHz trans-

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518

HODDICK

ET

AU.

AJR:140,

D
Fig.

1 -Diabetic

with

four

staphytococcal

renal

abscesses.

March

1983

A, Left

pole renal abscess

with perinephric
extension
and thickened
renal
(arrow).
B. Sonogram
of left renal abscess.
Poorly defined hypoechoic

lower

fascia
mass

(arrows)
without
acoustic
enhancement.
C and 0, Multiple
scesses (arrows)
and E, left renal abscess (arrow)
diagnosed
seen with sonography.

right renal abby CT but not

ducer. CT was performed

using a G.E. CT/T 8800 after intravenous
urographic
contrast
material.
Contiguous
scans were performed
at
1 cm

intervals

through

the

kidneys.

The diagnosis
of a renal or perirenal
abscess
was confirmed
by
surgery (six patients) or diagnostic
percutaneous
needle aspiration
(one patient).
In the other five patients,
CT and sonography
demonstrated
focal (two) or multifocal
(three) bacterial
nephritis.
None
of this

group

clinical

improvement

of patients

required

after

surgery

prolonged

and

antibiotic

there

was

gradual

therapy.

Results
Rena!

Abscesses

Three

patients

2 cm (fig.

1 ).

multiple
Bilateral

had

six proven

A fourth

patient

renal
with

bilateral
abscesses
smaller
staphylococcal
abscesses

diabetic
with the smallest
diagnosed
all the renal

abscess
abscesses

abscesses

systemic

larger

than

candidiasis

had

than
1 cm (fig.
2).
were
also noted
in a

about
2 cm. CT correctly
in this series.
With CT,

the renal
abscesses
defined,
low-density

characteristically
parenchymal

adjacent
renal fascia
which
were contiguous

was noted
in three
of the
with peninenal
fat. In two

lesions.

appeared
as
Thickening

well
of

abscesses
abscesses

Fig.

2.-Multiple

arrows).

Multiple

demonstrate

renal

small

renal

hepatic

abscesses

abscesses

systemic

arrow).

candidiasis

Sonography

(black
failed to

lesions.

confined
to the cortex
and
there was no fascial
thickening
Sonography

from

(white

correctly

not

adjacent
(fig. 1 D).

diagnosed

renal

to

peninenal

abscesses

fat,
in two

AJR:140,

March

RENAL

1983

AND

PERIRENAL

INFECTIONS

519

Fig. 3.-A.
Gas-forming
renal and
perirenal
abscesses.
CT also demonstrates focal bacterial
nephritis
(arrow).
Slight enlargement
of left psoas muscle
adjacent
to abscess.
B, Sonogram
ini-

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tially interpreted
Reverberation
in retrospect.
phritis seen

as showing no abscess.

from gas (arrows) noted

Focal area of bacterial
newith CT not identified.

poorly
defined
areas
of decreased
contrast
enhancement
on CT (fig. 5). Sonography
was abnormal
in only two of the
five patients
demonstrating
a focal,
hypoechoic,
solid mass.

In one

of these

involvement.

patients,

Clinical

CT

follow-up

months

demonstrated

ess on
showed

antibiotic
therapy.
interval improvement

showed
in the

resolution

multiple
five

of the

areas

patients
inflammatory

proc-

In two patients,
follow-up
at 4 and 6 weeks. There

a correlation
between
multiple
and a protracted
clinical
course

of

of 6-14

foci of involvement
with more gradual

CT
was

on CT
clinical

improvement.

Discussion
Fig.

4.-Diabetic

with

and sonography.
density

perirenal

abscess

correctly
by both CT
mass containing
lowperirenal
abscess
at

diagnosed

Perirenal

fat obliterated
by soft-tissue
(arrows). Proven Candida albicans

abscesses

surgery.

of

three

patients.

The

abscesses

appeared

as

either

complex
fluid collection
on hypoechoic
mass with poor
through
transmission.
In the patient with systemic
candidiasis, sonognaphy
was normal.
A false-negative
diagnosis
occurred
in another patient with a large abscess in the lower
pole of the left kidney (figs. 1 A-i D) in whom sonognaphy
failed

to demonstrate

three

other

smaller

abscesses.

The

CT correctly
diagnosed
all three patients
with surgically
proven peninephnic
abscesses
(figs. 3 and 4). The CT findings

included

peninenal

bubbles
(one
and thickening
nosed

two

falsely

negative

fluid

collections

patient)
with
of adjacent

of

the

three

(two

patients)

on gas

distortion
of the renal contour
renal fascia. Sonognaphy
diagpeninephnic

in a patient

with

abscesses,
a gas-forming

but

was

peninenal

or Mu!tifoca!

and
and

penirenal

abscesses

radiologists

alike.

be viewed
as
treated
interstitial

a pathologic
infections

evolve
into an acute
abscess.
Although
tenial nephnitis
gradually
improve
with
peninenal
therapy

abscesses
alone.

portance
because

generally

Therefore,

to distinguish
of the potential

jacent
fascia.
series

patients
antibiotics,

do not

respond

interstitial
infection
need for surgical

rounded

areas

Unlike
bacterial
distribution.
Also

Bacteria!

Five patients
were included
exhibited
single (two patients)

Nephritis

in this category.
All patients
on multiple
(three patients)

of the most
the sharp

adjacent
enhancing
poorly
defined
areas

generally

series

as
and

to antibiotic
clinical

im-

from an abscess
intervention.

of renal
abscesses

abscesses,
appear
as

without

significant

contrast

nephnitis,
strongly

abscesses
suggestive

do not
was ad-

peninephnic
extension
with thickening
of the renal
This finding
was not present
in two abscesses
in our
confined
to the cortex
and not contiguous
with pen-

renal fat. One

patients
was

detected
nience,

renal

with bacrenal
or

it is of considerable

In describing
the CT appearance
Rauschkolb
et al. [2] noted that renal

defined,

continues
Severe

continuum,
may liquefy

consistent
demarcation

CT features
among
our
of abscesses
from

renal
panenchyma
of focal bacterial

as opposed
nephnitis.

In describing
the gray-scale
sonographic
abscesses,
Wicks
et al. [1 ] noted
that

abscess.
Focal

may

enhancement.
have a loban

Abscess

of renal
clinicians

infections
inadequately

well
Perinephric

diagnosis

to challenge

must

be at least

by sonography.
as the abscesses
were

2-3

features
renal

cm in diameter

In addition

of renal

abscesses
in order

This is in keeping
with
missed
by sonognaphy

all 2 cm on smaller.

to the

to size

our

to be
expein our

limitations,

520

HODDICK

ET

AJR:140,

AL.

March

1983

Fig. 5.-Multifocal
bacterial
nephritis. A, Enlarged
right kidney with three
poorly defined
areas of decreased
enhancement
(arrowheads).
B, Sonogram
underestimates
extent of involvement
as
only single hypoechoic
area identified

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(arrows).

sonography
alterations
necting

cannot

define

fascial

of peninephnic
diagnostic
needle

scesses,

and

fat.

an aggressive

aspiration
may
filled
peninephnic

sonography.

approach

overcome
abscesses

The

only

thickening

on detect

Sonognaphy
aspiration
of

subtle

is useful
suspected

with

The

in diab-

abscess

missed

with

acute

pyelonephnitis.

Excretory

in this

unognams

in

three of these
patients
were normal.
The authors
concluded
that CT was more sensitive
than excretory
urography
in the
detection
of focal areas of interstitial
infection.
Lee et al. [7]
described

the

CT and

sonognaphic

features

of acute

bacterial
nephnitis
in 1 3 patients.
With sonography,
focal
bacterial
nephnitis
appeared
as hypoechoic

masses

without

definable

poorly
defined,
administration
emphasized
nephnitis

series

mal

low-density
of contrast

enhancement.

tended
as

multiple

negative

evidence

In one
a single

sonography

involvement,

was

clear-cut

of the

area

in

cases

where

areas

in

parenchyCT

the
were

showed

degree
identified.

antibiotic

1 . Wicks
Radio!
2.

3,
4.
5,

6.

7.

8.

of

although

clinical

nephnitis
severity

seemed
and

the

to
need

treatment.
this

is admittedly

a small

series

of

of both

renal

and

penirenal

infections.

REFERENCES

bacterial
patients

bacterial

increased

and further
studies
will need to corroborate
these
it seems that CT is the more sensitive
method for

diagnosis

sonography

infection,

to underestimate
abnormal

three

of abnormal

of focal

bacterial
In our

or multifocal

patients
findings,

to

intravenous
et al. [8]

of acute
focal
via sonography.

focal

focal

areas of
solid

corresponded

areas
on CT after
material.
Rosenfield

with either

sonognaphy

CT showed

demonstrated

that

These

the lobar
distribution
could
be diagnosed

of five patients

nephnitis,

whom

that

walls.

of multifocal
with

In conclusion,

series
was a gas-containing
abscess.
In retrospect,
pennephnic
gas could
be identified
(fig. 3), but this was ovenlooked
on the initial examination.
Hoffman
et al. [6] described
the CT features
in five diabetic
patients

well

for prolonged

percutaneous

some
of these
limitations.
Fluidmay be readily
diagnosed
by

peninephnic

presence

correlate

JD,

Thornbury

Clin North

Am

JR.

Acute

renal

infections

in adults.

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Rauschkolb
EN, SandIer CM, Sumant P, Childs TU. Computed
tomography
of renal inflammatory
disease.
J Comput Assist
Tomogr 1 982;6 : 502-506
Edell SL, Bonavita
JA. The sonographic
appearance
of acute
pyelonephnitis.
Radiology
1 979;1 32 : 683-685
Gelman
MU, Stone LB. Renal carbuncle:
early diagnosis
by
retropenitoneal
ultrasound.
Urology
1976;6: 103-107
Schneider
M, Becker JA, Stniano 5, Campos E. Sonographicradiographic
correlation
of renal and perirenal
infections.
AJR
1976;1 27: 1007-1
014
Hoffman
EP, Mindelzun
RE, Anderson
RU. CT in acute pyelonephnitis
associated
with diabetes.
Radiology
1 980; 1 35 : 691 695
Lee KTL, McClennan
BL, Melson GL, Stanley RJ. Acute focal
bacterial
nephnitis:
emphasis
on grey scale sonography
and
computed
tomography.
AJR 1 980;1 35 : 87-92
Rosenfield
AT, Glickman
MG, Taylor KJW, Crade M, Hodson
J. Acute focal bacterial
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Radio!ogy I 979;1 32 : 553-561