DOI: 10.1148/rg.281075171
Pyelonephritis: Radiologic-Pathologic Review1
William D. Craig, CDR, MC, USN,
Brent J. Wagner, MD, and
Mark D. Travis, LCDR, MC, USN
1 From the Department of Radiologic Pathology, Armed Forces Institute of Pathology, 6825 16th St, NW, Washington, DC 20306-6000 (W.D.C.); Department of Radiology and Radiological Sciences, Uniformed University of the Health Sciences, Bethesda, Md (W.D.C.); Department of Radiology, Reading Hospital and Medical Center, West Reading, Pa (B.J.W.); and the National Capitol Radiology Consortium, National Naval Medical Center, Bethesda, Md (M.D.T.). Received August 13, 2007; revision requested September 14 and received September 26; accepted September 28. All authors have no financial relationships to disclose.
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Figure 1a. Unilateral pyelitis in a patient with suspected acute bacterial pyelonephritis. (a, b) Axial (a) and oblique reconstructed (b) images from contrast material–enhanced computed tomography (CT) demonstrate thickening and asymmetric enhancement of the central collecting system. (arrowhead). The overlying parenchyma enhances normally and appears radiologically normal. (c) Photomicrograph (original magnification, x200; hematoxylineosin stain) shows acute inflammation of the renal pyelocaliceal system and intense acute inflammation by polymorphonuclear leukocytes in the renal papillary tip, with erosion or loss of the overlying transitional epithelium (urothelium). (Reprinted, with permission, from reference 9.)
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Figure 1b. Unilateral pyelitis in a patient with suspected acute bacterial pyelonephritis. (a, b) Axial (a) and oblique reconstructed (b) images from contrast material–enhanced computed tomography (CT) demonstrate thickening and asymmetric enhancement of the central collecting system. (arrowhead). The overlying parenchyma enhances normally and appears radiologically normal. (c) Photomicrograph (original magnification, x200; hematoxylineosin stain) shows acute inflammation of the renal pyelocaliceal system and intense acute inflammation by polymorphonuclear leukocytes in the renal papillary tip, with erosion or loss of the overlying transitional epithelium (urothelium). (Reprinted, with permission, from reference 9.)
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Figure 1c. Unilateral pyelitis in a patient with suspected acute bacterial pyelonephritis. (a, b) Axial (a) and oblique reconstructed (b) images from contrast material–enhanced computed tomography (CT) demonstrate thickening and asymmetric enhancement of the central collecting system. (arrowhead). The overlying parenchyma enhances normally and appears radiologically normal. (c) Photomicrograph (original magnification, x200; hematoxylineosin stain) shows acute inflammation of the renal pyelocaliceal system and intense acute inflammation by polymorphonuclear leukocytes in the renal papillary tip, with erosion or loss of the overlying transitional epithelium (urothelium). (Reprinted, with permission, from reference 9.)
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Figure 2. Acute bacterial pyelonephritis of the left kidney. Tomogram from intravenous pyelography demonstrates an enlarged left kidney with effacement of the central collecting system.
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Figure 3a. Acute bacterial pyelonephritis. (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis. (b) Color flow US image demonstrates diminished flow through the involved area.
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Figure 3b. Acute bacterial pyelonephritis. (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis. (b) Color flow US image demonstrates diminished flow through the involved area.
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Figure 4a. Severe unilateral acute bacterial pyelonephritis. (a) US image demonstrates a slightly enlarged right kidney that is otherwise unremarkable, belying the advanced disease. (b) CT scan shows the enlarged kidney with global decreased uptake of contrast material and multiple small low-attenuation foci from abscess pockets, findings that prompted nephrectomy. (c) Photograph of the resected gross specimen reveals multiple intrarenal abscesses that have begun to partially coalesce. Scale is in centimeters.
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Figure 4b. Severe unilateral acute bacterial pyelonephritis. (a) US image demonstrates a slightly enlarged right kidney that is otherwise unremarkable, belying the advanced disease. (b) CT scan shows the enlarged kidney with global decreased uptake of contrast material and multiple small low-attenuation foci from abscess pockets, findings that prompted nephrectomy. (c) Photograph of the resected gross specimen reveals multiple intrarenal abscesses that have begun to partially coalesce. Scale is in centimeters.
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Figure 4c. Severe unilateral acute bacterial pyelonephritis. (a) US image demonstrates a slightly enlarged right kidney that is otherwise unremarkable, belying the advanced disease. (b) CT scan shows the enlarged kidney with global decreased uptake of contrast material and multiple small low-attenuation foci from abscess pockets, findings that prompted nephrectomy. (c) Photograph of the resected gross specimen reveals multiple intrarenal abscesses that have begun to partially coalesce. Scale is in centimeters.
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Figure 5a. Masslike appearance of acute bacterial pyelonephritis. (a) US scan demonstrates a geographic, slightly lobulated "mass" (arrowhead) in the midpole of the left kidney, a finding that is worrisome for a solid tumor. (b) CT scan shows multifocal regions of diminished enhancement that extend to the periphery of the kidney, findings consistent with interstitial nephritis.
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Figure 5b. Masslike appearance of acute bacterial pyelonephritis. (a) US scan demonstrates a geographic, slightly lobulated "mass" (arrowhead) in the midpole of the left kidney, a finding that is worrisome for a solid tumor. (b) CT scan shows multifocal regions of diminished enhancement that extend to the periphery of the kidney, findings consistent with interstitial nephritis.
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Figure 6. Scintiscan obtained with technetium 99m dimercaptosuccinic acid demonstrates a photopenic, peripheral defect (arrow) in the upper lateral margin of the right kidney that correlates with an area of acute bacterial pyelonephritis.
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Figure 7. Acute bacterial pyelonephritis. (7) Unenhanced CT scan from a clinically documented case of acute bacterial pyelonephritis shows asymmetric enlargement and absence of the pyramids of the right kidney (cf the preserved pyramids [arrow] in the normal left kidney). Loss of the renal pyramids is a nonspecific marker for edema, which is more typically seen in obstruction related to calculi.
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Figure 8. Acute bacterial pyelonephritis. (8) Unenhanced CT scan demonstrates multiple, scattered, round and oval hyperattenuation foci within the left kidney, findings indicative of hemorrhagic acute bacterial pyelonephritis.
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Figure 9a. Acute bacterial nephritis. (a) Photograph of the cut surface of a resected kidney shows a wedge-shaped, lighter region of renal cortex that represents acute bacterial nephritis. (b) Contrast-enhanced CT scan demonstrates decreased enhancement throughout the same area. Note the sharp transition (arrowhead) between normal and abnormal kidney. (c) Photomicrograph (original magnification, x400; hematoxylineosin stain) shows a duct (arrowhead) that contains a cast of polymorphonuclear lymphocytes. Pus casts may be seen in the urine of patients with acute bacterial pyelonephritis. (Figs 9a and 9c reprinted, with permission, from reference 9.)
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Figure 9b. Acute bacterial nephritis. (a) Photograph of the cut surface of a resected kidney shows a wedge-shaped, lighter region of renal cortex that represents acute bacterial nephritis. (b) Contrast-enhanced CT scan demonstrates decreased enhancement throughout the same area. Note the sharp transition (arrowhead) between normal and abnormal kidney. (c) Photomicrograph (original magnification, x400; hematoxylineosin stain) shows a duct (arrowhead) that contains a cast of polymorphonuclear lymphocytes. Pus casts may be seen in the urine of patients with acute bacterial pyelonephritis. (Figs 9a and 9c reprinted, with permission, from reference 9.)
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Figure 9c. Acute bacterial nephritis. (a) Photograph of the cut surface of a resected kidney shows a wedge-shaped, lighter region of renal cortex that represents acute bacterial nephritis. (b) Contrast-enhanced CT scan demonstrates decreased enhancement throughout the same area. Note the sharp transition (arrowhead) between normal and abnormal kidney. (c) Photomicrograph (original magnification, x400; hematoxylineosin stain) shows a duct (arrowhead) that contains a cast of polymorphonuclear lymphocytes. Pus casts may be seen in the urine of patients with acute bacterial pyelonephritis. (Figs 9a and 9c reprinted, with permission, from reference 9.)
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Figure 10. Acute bacterial pyelonephritis. Delayed phase CT scan obtained through the midpole of the right kidney demonstrates an intense persistent nephrogram (arrowhead) around the posterior rim of the kidney along two medullary rays.
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Figure 11. Acute bacterial pyelonephritis caused by hematologic seeding in a patient with Staphylococcus aureus endocarditis. CT scan demonstrates peripheral low-attenuation lesions (arrowheads) that are maturing into small abscess cavities. In such cases, blood and urine cultures grow the same organism.
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Figure 12. Sarcoidosis. CT scan shows multiple geographic hypoattenuation regions throughout both kidneys that are related to the patient’s sarcoidosis. The defects are indistinguishable from those caused by pyelonephritis, the most commonly imaged interstitial nephritis.
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Figure 13a. Intrarenal abscess with perinephric extension. (a) CT scan demonstrates an abscess cavity with a peripheral enhancing rim but no central enhancement in the right kidney. (b) Delayed phase CT scan shows secondary signs that include delayed clearance of contrast material as evidenced by asymmetric visualization of the enhanced pyramids (arrow), stranding throughout the perinephric space, and thickening of Gerota fascia (arrowhead).
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Figure 13b. Intrarenal abscess with perinephric extension. (a) CT scan demonstrates an abscess cavity with a peripheral enhancing rim but no central enhancement in the right kidney. (b) Delayed phase CT scan shows secondary signs that include delayed clearance of contrast material as evidenced by asymmetric visualization of the enhanced pyramids (arrow), stranding throughout the perinephric space, and thickening of Gerota fascia (arrowhead).
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Figure 14a. Early and mature abscess cavities. (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney. (b) On a US scan of a more mature abscess, the cavity is better defined, with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion.
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Figure 14b. Early and mature abscess cavities. (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney. (b) On a US scan of a more mature abscess, the cavity is better defined, with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion.
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Figure 15. MR imaging of acute bacterial pyelonephritis. Sagittal short inversion-time inversion recovery image of the right kidney obtained after gadolinium administration demonstrates signal drop off in the normal middle and lower renal poles due to normal perfusion and uptake of contrast agent. The infected upper pole, with its compromised perfusion, remains bright (arrowhead) and stands out in relief. (Courtesy of Gael J. Lonergan, MD, Dell Children’s Hospital, Austin, Tex.)
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Figure 16a. Chronic pyelonephritis. (a) Unenhanced CT scan shows a small, deformed right kidney with multiple deep scars and dystrophic calcifications. (b) Photograph of the resected kidneys demonstrates extensive bilateral scar formation. (Reprinted, with permission, from reference 9.)
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Figure 16b. Chronic pyelonephritis. (a) Unenhanced CT scan shows a small, deformed right kidney with multiple deep scars and dystrophic calcifications. (b) Photograph of the resected kidneys demonstrates extensive bilateral scar formation. (Reprinted, with permission, from reference 9.)
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Figure 17. Bilateral emphysematous pyelonephritis. Abdominal radiograph from an intravenous pyelographic study demonstrates lucent air that outlines both kidneys (arrowheads). Gas has also escaped into the retroperitoneum and appears in linear collections along the left paraspinous region (arrow).
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Figure 18a. Emphysematous pyelonephritis. (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact. (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air.
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Figure 18b. Emphysematous pyelonephritis. (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact. (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air.
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Figure 19a. Types 1 and 2 emphysematous pyelonephritis. (a) Unenhanced CT scan demonstrates type 1 emphysematous pyelonephritis, which appears as a large area of air that has completely destroyed and distorted the right kidney. Note the absence of fluid within or around the kidney. (b) Unenhanced CT scan of type 2 emphysematous pyelonephritis shows air within both the renal parenchyma and the collecting system, with associated fluid collections along the lateral border.
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Figure 19b. Types 1 and 2 emphysematous pyelonephritis. (a) Unenhanced CT scan demonstrates type 1 emphysematous pyelonephritis, which appears as a large area of air that has completely destroyed and distorted the right kidney. Note the absence of fluid within or around the kidney. (b) Unenhanced CT scan of type 2 emphysematous pyelonephritis shows air within both the renal parenchyma and the collecting system, with associated fluid collections along the lateral border.
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Figure 20a. Emphysematous pyelitis. CT images of the abdomen (a) and pelvis (b) demonstrate bilateral collections of air within the central collecting systems (arrowhead in a) and along each ureter (arrowheads in b).
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Figure 20b. Emphysematous pyelitis. CT images of the abdomen (a) and pelvis (b) demonstrate bilateral collections of air within the central collecting systems (arrowhead in a) and along each ureter (arrowheads in b).
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Figure 22. Xanthogranulomatous pyelonephritis with staghorn calculus. Abdominal radiograph shows a classic staghorn calculus secondary to xanthogranulomatous pyelonephritis in the location of the right kidney.
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Figure 23a. Xanthogranulomatous pyelonephritis. (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi, with distention of the right collecting system secondary to inflammatory debris. (b) US scan also shows the dilated collecting system (arrowheads) and a shadowing calculus (arrow). (c) Photograph of a cut specimen clearly depicts a complex, milky infiltrate that fills and expands the collecting system.
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Figure 23b. Xanthogranulomatous pyelonephritis. (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi, with distention of the right collecting system secondary to inflammatory debris. (b) US scan also shows the dilated collecting system (arrowheads) and a shadowing calculus (arrow). (c) Photograph of a cut specimen clearly depicts a complex, milky infiltrate that fills and expands the collecting system.
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Figure 23c. Xanthogranulomatous pyelonephritis. (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi, with distention of the right collecting system secondary to inflammatory debris. (b) US scan also shows the dilated collecting system (arrowheads) and a shadowing calculus (arrow). (c) Photograph of a cut specimen clearly depicts a complex, milky infiltrate that fills and expands the collecting system.
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Figure 24a. Focal xanthogranulomatous pyelonephritis. (a) Contrast-enhanced CT scan demonstrates a thick-walled, peripherally enhancing, low-attenuation lesion. (b) Coronal contrast-enhanced T1-weighted MR image demonstrates the lesion with very similar characteristics. (c) Photograph of the cut specimen shows the thick-walled, yellowish capsule of the focal lesion. (d) Photomicrograph (original magnification, x400; hematoxylineosin stain) shows a large collection of foamy macrophages and histiocytes (arrowhead). (Reprinted, with permission, from reference 9.)
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Figure 24b. Focal xanthogranulomatous pyelonephritis. (a) Contrast-enhanced CT scan demonstrates a thick-walled, peripherally enhancing, low-attenuation lesion. (b) Coronal contrast-enhanced T1-weighted MR image demonstrates the lesion with very similar characteristics. (c) Photograph of the cut specimen shows the thick-walled, yellowish capsule of the focal lesion. (d) Photomicrograph (original magnification, x400; hematoxylineosin stain) shows a large collection of foamy macrophages and histiocytes (arrowhead). (Reprinted, with permission, from reference 9.)
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Figure 24c. Focal xanthogranulomatous pyelonephritis. (a) Contrast-enhanced CT scan demonstrates a thick-walled, peripherally enhancing, low-attenuation lesion. (b) Coronal contrast-enhanced T1-weighted MR image demonstrates the lesion with very similar characteristics. (c) Photograph of the cut specimen shows the thick-walled, yellowish capsule of the focal lesion. (d) Photomicrograph (original magnification, x400; hematoxylineosin stain) shows a large collection of foamy macrophages and histiocytes (arrowhead). (Reprinted, with permission, from reference 9.)
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Figure 24d. Focal xanthogranulomatous pyelonephritis. (a) Contrast-enhanced CT scan demonstrates a thick-walled, peripherally enhancing, low-attenuation lesion. (b) Coronal contrast-enhanced T1-weighted MR image demonstrates the lesion with very similar characteristics. (c) Photograph of the cut specimen shows the thick-walled, yellowish capsule of the focal lesion. (d) Photomicrograph (original magnification, x400; hematoxylineosin stain) shows a large collection of foamy macrophages and histiocytes (arrowhead). (Reprinted, with permission, from reference 9.)
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Figure 26a. Papillary necrosis related to tuberculosis. (a–c) Photographs of a cut gross specimen show the early necrosis of the medullary tip (black spot in a). Once devitalized, the papilla sloughs off, leaving a defect (cavity in b) within the medulla that is retrievable (necrotic tissue in c). (d) Collimated image from intravenous urography demonstrates multiple papillary cavities.
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Figure 26b. Papillary necrosis related to tuberculosis. (a–c) Photographs of a cut gross specimen show the early necrosis of the medullary tip (black spot in a). Once devitalized, the papilla sloughs off, leaving a defect (cavity in b) within the medulla that is retrievable (necrotic tissue in c). (d) Collimated image from intravenous urography demonstrates multiple papillary cavities.
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Figure 26c. Papillary necrosis related to tuberculosis. (a–c) Photographs of a cut gross specimen show the early necrosis of the medullary tip (black spot in a). Once devitalized, the papilla sloughs off, leaving a defect (cavity in b) within the medulla that is retrievable (necrotic tissue in c). (d) Collimated image from intravenous urography demonstrates multiple papillary cavities.
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Figure 26d. Papillary necrosis related to tuberculosis. (a–c) Photographs of a cut gross specimen show the early necrosis of the medullary tip (black spot in a). Once devitalized, the papilla sloughs off, leaving a defect (cavity in b) within the medulla that is retrievable (necrotic tissue in c). (d) Collimated image from intravenous urography demonstrates multiple papillary cavities.
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Figure 27. Tuberculosis. Retrograde pyelogram shows that the upper pole calix is stenotic (arrow) with associated papillary necrosis. The adjacent calix is fibrotic and distorted as well.
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Figure 28a. Calcifications of tuberculosis. (a) Abdominal radiograph demonstrates extensive calcifications forming a cast of the kidney and ureter. (b) Photograph of the cut specimen shows complete replacement of the normal kidney by inflammatory debris.
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Figure 28b. Calcifications of tuberculosis. (a) Abdominal radiograph demonstrates extensive calcifications forming a cast of the kidney and ureter. (b) Photograph of the cut specimen shows complete replacement of the normal kidney by inflammatory debris.
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Figure 29a. Malacoplakia. (a, b) Unenhanced CT images obtained at different levels (a higher than b) demonstrate symmetrically enlarged kidneys. (c) Corresponding T1-weighted MR image shows globally enlarged kidneys of intermediate signal intensity. (d) Photograph of the bisected specimen reveals a whitish infiltrate that nearly completely replaces the renal parenchyma. Scale is in centimeters. (e) Photomicrograph (original magnification, x400; von Kossa calcium stain) shows calcium deposition in a number of cells (Michaelis-Gutmann bodies), a finding that is characteristic of renal malacoplakia. (Reprinted, with permission, from reference 9.)
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Figure 29b. Malacoplakia. (a, b) Unenhanced CT images obtained at different levels (a higher than b) demonstrate symmetrically enlarged kidneys. (c) Corresponding T1-weighted MR image shows globally enlarged kidneys of intermediate signal intensity. (d) Photograph of the bisected specimen reveals a whitish infiltrate that nearly completely replaces the renal parenchyma. Scale is in centimeters. (e) Photomicrograph (original magnification, x400; von Kossa calcium stain) shows calcium deposition in a number of cells (Michaelis-Gutmann bodies), a finding that is characteristic of renal malacoplakia. (Reprinted, with permission, from reference 9.)
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Figure 29c. Malacoplakia. (a, b) Unenhanced CT images obtained at different levels (a higher than b) demonstrate symmetrically enlarged kidneys. (c) Corresponding T1-weighted MR image shows globally enlarged kidneys of intermediate signal intensity. (d) Photograph of the bisected specimen reveals a whitish infiltrate that nearly completely replaces the renal parenchyma. Scale is in centimeters. (e) Photomicrograph (original magnification, x400; von Kossa calcium stain) shows calcium deposition in a number of cells (Michaelis-Gutmann bodies), a finding that is characteristic of renal malacoplakia. (Reprinted, with permission, from reference 9.)
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Figure 29d. Malacoplakia. (a, b) Unenhanced CT images obtained at different levels (a higher than b) demonstrate symmetrically enlarged kidneys. (c) Corresponding T1-weighted MR image shows globally enlarged kidneys of intermediate signal intensity. (d) Photograph of the bisected specimen reveals a whitish infiltrate that nearly completely replaces the renal parenchyma. Scale is in centimeters. (e) Photomicrograph (original magnification, x400; von Kossa calcium stain) shows calcium deposition in a number of cells (Michaelis-Gutmann bodies), a finding that is characteristic of renal malacoplakia. (Reprinted, with permission, from reference 9.)
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Figure 29e. Malacoplakia. (a, b) Unenhanced CT images obtained at different levels (a higher than b) demonstrate symmetrically enlarged kidneys. (c) Corresponding T1-weighted MR image shows globally enlarged kidneys of intermediate signal intensity. (d) Photograph of the bisected specimen reveals a whitish infiltrate that nearly completely replaces the renal parenchyma. Scale is in centimeters. (e) Photomicrograph (original magnification, x400; von Kossa calcium stain) shows calcium deposition in a number of cells (Michaelis-Gutmann bodies), a finding that is characteristic of renal malacoplakia. (Reprinted, with permission, from reference 9.)
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Copyright © 2008 by the Radiological Society of North America.
