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Child with acute lobar nephronia.

Vijayakumar M, Prahlad N, Nandhini G, Prasad N, Muralinath S - Indian J Nephrol (2010)

Bottom Line: A five-year-old girl child presented to us with a history of two weeks high grade fever treated outside with intensive antibiotic therapy for an ultrasound abdomen finding of hypoechoic lesion in the midpole of the left kidney.As fever and sonographic findings persisted, a CT abdomen was done, which showed features of lobar nephronia but reported as Wilm's tumor.Child was continued on antibiotics and fever and sonographic findings improved.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatric Nephrology, Mehta Children's Hospital, Chennai - 600 031, India.

ABSTRACT
A five-year-old girl child presented to us with a history of two weeks high grade fever treated outside with intensive antibiotic therapy for an ultrasound abdomen finding of hypoechoic lesion in the midpole of the left kidney. As fever and sonographic findings persisted, a CT abdomen was done, which showed features of lobar nephronia but reported as Wilm's tumor. Child underwent open biopsy and the diagnosis of lobar nephronia was confirmed. Child was continued on antibiotics and fever and sonographic findings improved.

No MeSH data available.


Related in: MedlinePlus

Contrast enhanced computed tomography picture of the lesion in the midpole of left kidney-along the column of bertini from papilla to cortex with calyceal effacement and poor enhancement of IV contrast
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Figure 0001: Contrast enhanced computed tomography picture of the lesion in the midpole of left kidney-along the column of bertini from papilla to cortex with calyceal effacement and poor enhancement of IV contrast

Mentions: On admission, child had high grade fever, left loin pain, dysuria and severe vomiting. Child was toxic and hydration was poor. There was no evidence of shock and child had pallor. Vital signs were normal and BP was 92/70 mm/Hg in the right upper limb. No palpable mass per abdomen but left renal tenderness was present. Other systemic examination was essentially normal. Laboratory evaluation showed more than 10 WBC/HPF in urine, pus cells, pus cell casts and nonnephrotic proteinuria. Urine and blood cultures repeated were sterile. Polymorphonuclear leucocytosis, elevated ESR and positive CRP were noted. Fortunately, her renal functions were normal. USG abdomen showed hypoechoic lesion of 2 cm diameter near the hilum of the left kidney which was diagnosed as ALN by our radiologist. Child was treated with IV fluids, antiemetics and tolerable oral diet. She had IV antibiotics, ceftrioxone and tazobactam combination, amikacin and ofloxacin for seven days, as antibiotics could not be decided due to sterile cultures. Fever spikes were persisting and the repeat USG abdomen showed persistence of the lesion. Fearing a renal abscess and to decide on drainage of the pus from the site of abscess, a contrast enhanced CT abdomen was done outside our center. The CT scan showed a moderately well defined hyperdense lesion of 4 × 3cm in the interpolar region of the left kidney in the cortex and medulla with focal necrosis [Figure 1]. The surface appeared puckered. The lesion had moderate enhancement with focal irregular peripheral nonenhancing area. Further it was distorting the interpolar calyceal collecting system. Mild thickening of the left latero-conal and posterior para-renal fasciae was noted. Few enlarged lymph nodes were seen in the left renal hilum. There was double renal artery supply to the left kidney. The radiologist outside opined this as Wilm’s tumor with paraaortic lymphadenopathy for us to confirm with histopathology. The pediatric surgical team was involved in the management from this stage as a diagnosis of Wilm’s tumor was given by the outside radiologist, which was disputed by our radiologist. The CT findings had liquefactive areas which was suspected as pus in the centre of the lesion needing drainage as per our radiologist but the outside radiologist thought it as a necrotic area of a suspected Wilm’s tumor. Parents were counselled and open biopsy was carried out. The lesion measured 4 × 3 cm in the interpolar region of the left kidney in the cortex and medulla with distortion of the collecting system. The lesion showed a bluish area of inflammation, from which few drops of pus were drained, and a wedge biopsy was taken from the discoloured region. Histopathological examination of the renal tissue showed features of dense interstitial and glomerular infiltrates of lymphocytes, plasma cells and neutrophils. Sheets of histiocytes were seen focally. There was no evidence of malignancy and the impression was subacute inflammation with histiocytic reaction [Figure 2]. Child was continued on IV antibiotics for total two weeks and full dose oral antibiotics for one more week and later kept on chemoprophylaxis. Child became afebrile with the drainage of pus during the surgical procedure and on continuation of antibiotics by 10thday of admission. On follow-up, a DMSA scan was done to evaluate the progress in the child which showed left kidney had mildly reduced uptake with a small photopenic defect in the lateral border [Figure 3]. Right kidney had adequate uptake with smooth rounded cortical margins. After one month, a voiding cystourethrogram was done to rule out vesicoureteric reflux (VUR) and it was normal. Child is being followed up with chemoprophylaxis which is being planned for at least 6 months.Figure 1


Child with acute lobar nephronia.

Vijayakumar M, Prahlad N, Nandhini G, Prasad N, Muralinath S - Indian J Nephrol (2010)

Contrast enhanced computed tomography picture of the lesion in the midpole of left kidney-along the column of bertini from papilla to cortex with calyceal effacement and poor enhancement of IV contrast
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2966985&req=5

Figure 0001: Contrast enhanced computed tomography picture of the lesion in the midpole of left kidney-along the column of bertini from papilla to cortex with calyceal effacement and poor enhancement of IV contrast
Mentions: On admission, child had high grade fever, left loin pain, dysuria and severe vomiting. Child was toxic and hydration was poor. There was no evidence of shock and child had pallor. Vital signs were normal and BP was 92/70 mm/Hg in the right upper limb. No palpable mass per abdomen but left renal tenderness was present. Other systemic examination was essentially normal. Laboratory evaluation showed more than 10 WBC/HPF in urine, pus cells, pus cell casts and nonnephrotic proteinuria. Urine and blood cultures repeated were sterile. Polymorphonuclear leucocytosis, elevated ESR and positive CRP were noted. Fortunately, her renal functions were normal. USG abdomen showed hypoechoic lesion of 2 cm diameter near the hilum of the left kidney which was diagnosed as ALN by our radiologist. Child was treated with IV fluids, antiemetics and tolerable oral diet. She had IV antibiotics, ceftrioxone and tazobactam combination, amikacin and ofloxacin for seven days, as antibiotics could not be decided due to sterile cultures. Fever spikes were persisting and the repeat USG abdomen showed persistence of the lesion. Fearing a renal abscess and to decide on drainage of the pus from the site of abscess, a contrast enhanced CT abdomen was done outside our center. The CT scan showed a moderately well defined hyperdense lesion of 4 × 3cm in the interpolar region of the left kidney in the cortex and medulla with focal necrosis [Figure 1]. The surface appeared puckered. The lesion had moderate enhancement with focal irregular peripheral nonenhancing area. Further it was distorting the interpolar calyceal collecting system. Mild thickening of the left latero-conal and posterior para-renal fasciae was noted. Few enlarged lymph nodes were seen in the left renal hilum. There was double renal artery supply to the left kidney. The radiologist outside opined this as Wilm’s tumor with paraaortic lymphadenopathy for us to confirm with histopathology. The pediatric surgical team was involved in the management from this stage as a diagnosis of Wilm’s tumor was given by the outside radiologist, which was disputed by our radiologist. The CT findings had liquefactive areas which was suspected as pus in the centre of the lesion needing drainage as per our radiologist but the outside radiologist thought it as a necrotic area of a suspected Wilm’s tumor. Parents were counselled and open biopsy was carried out. The lesion measured 4 × 3 cm in the interpolar region of the left kidney in the cortex and medulla with distortion of the collecting system. The lesion showed a bluish area of inflammation, from which few drops of pus were drained, and a wedge biopsy was taken from the discoloured region. Histopathological examination of the renal tissue showed features of dense interstitial and glomerular infiltrates of lymphocytes, plasma cells and neutrophils. Sheets of histiocytes were seen focally. There was no evidence of malignancy and the impression was subacute inflammation with histiocytic reaction [Figure 2]. Child was continued on IV antibiotics for total two weeks and full dose oral antibiotics for one more week and later kept on chemoprophylaxis. Child became afebrile with the drainage of pus during the surgical procedure and on continuation of antibiotics by 10thday of admission. On follow-up, a DMSA scan was done to evaluate the progress in the child which showed left kidney had mildly reduced uptake with a small photopenic defect in the lateral border [Figure 3]. Right kidney had adequate uptake with smooth rounded cortical margins. After one month, a voiding cystourethrogram was done to rule out vesicoureteric reflux (VUR) and it was normal. Child is being followed up with chemoprophylaxis which is being planned for at least 6 months.Figure 1

Bottom Line: A five-year-old girl child presented to us with a history of two weeks high grade fever treated outside with intensive antibiotic therapy for an ultrasound abdomen finding of hypoechoic lesion in the midpole of the left kidney.As fever and sonographic findings persisted, a CT abdomen was done, which showed features of lobar nephronia but reported as Wilm's tumor.Child was continued on antibiotics and fever and sonographic findings improved.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatric Nephrology, Mehta Children's Hospital, Chennai - 600 031, India.

ABSTRACT
A five-year-old girl child presented to us with a history of two weeks high grade fever treated outside with intensive antibiotic therapy for an ultrasound abdomen finding of hypoechoic lesion in the midpole of the left kidney. As fever and sonographic findings persisted, a CT abdomen was done, which showed features of lobar nephronia but reported as Wilm's tumor. Child underwent open biopsy and the diagnosis of lobar nephronia was confirmed. Child was continued on antibiotics and fever and sonographic findings improved.

No MeSH data available.


Related in: MedlinePlus