Kidney carbuncle is one of the forms of acute pyelonephritis, in which a purulent-necrotic pathological process develops in a limited area of the cortical layer of the kidney.
Etiology and pathogenesis. Most often, a kidney carbuncle occurs due to a blockage of a large end vessel of the kidney by a microbial embolus that has penetrated from the focus of inflammation into the body (furuncle, carbuncle, mastitis, osteomyelitis, etc.) with blood flow. At the same time, blood circulation is disrupted in a limited area of the cortical layer of the kidney, which leads to its ischemia and necrosis, in the future, microorganisms that have penetrated here cause a purulent-inflammatory process. A carbuncle can also develop due to the fusion of small pustules with apostematous pyelonephritis, compression of the final vessel of the cortical layer of the kidney by purulent-inflammatory infiltrate. The carbuncle can be single or multiple, it has a different size, it is localized more often in the cortical layer of the kidney, but sometimes it also extends to the cerebral layer. The carbuncle is raised above the surface of the kidney, contains a large number of small pustules.
In the later stages, purulent melting of the carbuncle occurs. The inflammatory process in the paranephral tissue can be limited to leukocyte infiltration, but it can lead to its purulent melting. With a favorable course, the infiltrate resorption occurs with the formation of connective tissue in its place.
Clinic. The manifestations of the kidney carbuncle are similar to the clinical picture of other forms of purulent pyelonephritis. The main signs are a sharp general weakness, pallor of the skin, high body temperature of a hectic nature with amazing chills and torrential sweats, oliguria, a decrease in blood pressure. Local symptoms: tension of the muscles of the anterior abdominal wall and lower back, a sharply positive symptom of Pasternatsky, sometimes an enlarged and painful kidney is clearly palpated, but these local symptoms are not always detected. There is a high leukocytosis with a shift of the leukocyte formula to the left.
Diagnostics. The diagnosis is difficult due to the fact that with a single kidney carbuncle, the function of the affected kidney is not disturbed for a long time, and there are no changes in the urine. The most valuable in the diagnosis of a kidney carbuncle are X-ray, isotope and ultrasound methods of examination. On the overview image of the urinary tract, you can find an increase in the size of the kidney segment, a focal bulge of its external contour, the disappearance of the contour of the lumbar muscle on the side of the lesion. Excretory urograms or retrograde pyelogram reveal either compression of the calyx or pelvis, or amputation of one or more calyx. On the renal arteriograms in the arterial phase, a non-vascular area in the cortical layer of the kidney is determined, and on the nephrogram – a wedge-shaped image defect. Due to the predominance of general symptoms of the infectious process, the kidney carbuncle can be mistaken for an infectious disease, sometimes for a tumor of the kidney parenchyma, suppuration of a solitary kidney cyst, acute cholecystitis.
Treatment. Massive antibacterial therapy is carried out, but it cannot lead to a cure, since medications do not enter the lesion due to a violation of blood circulation in the kidney carbuncle. In the first 2-3 days of the disease, surgical treatment is performed – decapsulation of the kidney, excision of the carbuncle and drainage of the parotid fiber. At the same time, the disturbed passage of urine is restored. With multiple kidney carbuncles that have destroyed the entire parenchyma, and a functioning opposite kidney, nephrectomy is indicated, especially in elderly and senile people.
Prevention is provided by the timely initiation of rational therapy of acute pyelonephritis, as well as purulent-inflammatory processes of various localization.
Forecast. The prognosis depends on the timeliness of surgical intervention. Procrastination with it can lead to death and sepsis. With a timely operation, the prognosis is favorable.