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UROLOGICAL IMAGES
Year : 2019  |  Volume : 35  |  Issue : 3  |  Page : 240-241
 

Alkaline-encrusting pyelitis – A rare disastrous complication postPCNL leading to chronic renal failure


Department of Urology, PGIMER, Chandigarh, India

Date of Submission28-Apr-2019
Date of Acceptance01-Jun-2019
Date of Web Publication2-Jul-2019

Correspondence Address:
Kalpesh Parmar
Department of Urology, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/iju.IJU_126_19

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   Abstract 

Alkaline-encrusting pyelitis (AEP) is a severe form of infectious disease characterized by encrustation along the lining of the urinary tract leading to loss of renal function. Common predisposing factors are chronic infection, immunosuppression, and endourology procedures. Urea-producing organisms arefrequently associated, and urine alkalization leads to calcific deposition in the pelvicalyceal system. We present a 23-year male with AEP in a solitary kidney leading to chronic renal failure postpercutaneous nephrolithotomy for renal stones.



How to cite this article:
Parmar K, Thakur A, Tyagi S. Alkaline-encrusting pyelitis – A rare disastrous complication postPCNL leading to chronic renal failure. Indian J Urol 2019;35:240-1

How to cite this URL:
Parmar K, Thakur A, Tyagi S. Alkaline-encrusting pyelitis – A rare disastrous complication postPCNL leading to chronic renal failure. Indian J Urol [serial online] 2019 [cited 2019 Jul 20];35:240-1. Available from: http://www.indianjurol.com/text.asp?2019/35/3/240/261924


A 23-year-old male presented with left flank pain. On evaluation, plain X-ray showed multiple left radiopaque shadows at L2–L3 level [Figure 1]a. Intravenous urogram showed left solitary functioning kidney with hydronephrosis and the presence of multiple renal stones with hypoplastic right kidney [Figure 1]b. Routine workup including hemogram, renal function test, calcium, uric acid, and urine analysis was within the normal limits. Percutaneous nephrolithotomy (PCNL) was performed after written informed consent by standard technique using mid and inferior posterior calyx puncture, and complete stone clearance was achieved. The patient was discharged on day 4 after surgery. He presented 6 days later with urine leak from nephrostomy site for which double-J stent and urethral catheter were placed. The renal functions were normal, and urine culture was sterile. In view of persistent leak, contrast-enhanced computed tomography (CT) urography was done which revealed the site of leak from the inferior calyx [Figure 2]a. Percutaneous nephrostomy (PCN) was placed through the inferior calyx, and clear urine was drained. The leak subsided within a day, and the patient was discharged; however, he returned a month later with high-grade fever, vomiting, and oliguria. On evaluation, his serum creatinine was 9.4 mg/dl and total leukocyte count of 24000/mcL. The patient was started on IV antibiotics (third-generation cephalosporin) and given two sessions of hemodialysis after nephrology evaluation. Noncontrast CT abdomen revealed left kidney hydronephrosis with calcific encrustation of the entire renal pelvis and upper ureter with PCN in situ [Figure 2]b. Alkaline-encrusting pyelitis (AEP) was the working diagnosis, and metabolic workup showed urine pH of 9.2 and serum calcium, uric acid, and citrate all within the normal limits. Extended urine culture showed Corynebacterium growth with 50–60 pus cells and confirmed the diagnosis of AEP. The serum creatinine was 3.7 mg/dl and total leukocyte counts were 9800/mcL.
Figure 1: (a) X-ray kidney, ureter, and bladder showing left radiopaque dense shadows at L2–L3 level on the left side (white solid arrow). (b) Intravenous pyelogram showing left solitary functioning kidney with presence of multiple renal stones (white solid arrow)

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Figure 2: (a) Computed tomography abdomen images (axial) showing renal parenchymal enhancement with site of urine leak and double-J stent in situ(white solid arrow). (b) Noncontrast computed tomography images (coronal) showing dense calcific encrustation along the whole lining of the pelvicalyceal system and ureter (white solid arrow)

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AEP is characterized by encrustation along the whole lining of the urinary tract. Corynebacterium, a urea-splitting organism, is the most common causative agent. The high urine pH favors precipitation of calcific deposits along the lining of the urinary tract.[1] It is reported in renal transplant recipients.[2] Other predisposing factors are immunosuppression, endourological procedures, and chronic urinary infection.[3] Devine et al. recently reported a case of AEP in a renal allograft recipient with multiple risk factors.[4] Post-PCNL, the sequence of events leading to AEP has never been reported. AEP should be suspected if after intervention, imaging shows calcific deposit in the urothelium with alkaline urine and Corynebacterium growth on culture. The patient was started on antibiotic vancomycin, Vitamin C supplements, and Suby G solution irrigation through the PCN and kept on close follow-up. His creatinine reached nadir 2.1 mg/dl, and urine output from PCN was 2.4 l.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We sincerely thank Dr. Ujwal Gorsi, Assistant Professor, Department of Radiology, for providing us with edited good quality radiology images of the patient.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

 
   References Top

1.
Morales JM, Aguado JM, Diaz-Gonzalez R, Salto E, Andres A, Campo C,et al. Alkaline-encrusted pyelitis/cystitis and urinary tract infection due to Corynebacterium urealyticu m: A new severe complication after renal transplantation. Transplant Proc 1992;24:81-2.  Back to cited text no. 1
    
2.
Lee R, Clement MR, Carr MC, Canning DA, Brayman KL. Successful treatment of encrusted cystitis and pyelitis with preservation of renal graft. Transplantation 2004;78:302-3.  Back to cited text no. 2
    
3.
Pagnoux C, Bérezné A, Damade R, Paillot J, Aouizerate J, Le Guern V, et al. Encrusting cystitis due to Corynebacterium urealyticum in a patient with ANCA-associated vasculitis: Case report and review of the literature. Semin Arthritis Rheum 2011;41:297-300.  Back to cited text no. 3
    
4.
Devine PA, Courtney AE. Alkaline-encrusted pyelitis in a renal allograft. Kidney Int Rep 2019;4:174-7.  Back to cited text no. 4
    


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