Compurerized Medical Imagmg and Gra,vhics, Vol. 16. No. 4, pp. 297-299. Printed in the U.S.A. All rights reserved.
1992 Copyright8
0895-611 l/92 15.00 + .oO PressLid. 1992 Pergamon
ACUTE PYELONEPHRITIS AFTER TRANSREmAL ULTRASONOGRAPHICALLY GUIDED BIOPSY OF THE PROSTATE: :DIAGNOSIS BY COMPUTED TOMOGRAPHY
R.hett D. Krause*, Joseph B. Dowdt, Carl R. Larsen*>*, John T. Cuttino, Jr.*, and Francis J. Scholz* Departments
of *Diagnostic
Radiology
and +Urology, Lahey Clinic Medical Center, Burlington,
MA 01805
(Received I7 December 1991) Abstract-Acute pyelonephritls developed in a 67-yr-old man after transrectal ultrasonographically guided biopsy of the prostate. The clinical presentation and results of excretory urography were nondlagnostic. Diagnosis was made by computed tolmography, which was delayed 12 h after i.v. administration of contrast medium. Key Words: Acute pyelonephritis, Transrectal ultrasonographically guided biopsy, Prostate
INTROIDUCIION
(40.6’C) and rigors. On physical examination, the prostate was tender, but no tenderness was felt over the costovertebral angle. Results of blood and urine cultures were positive for Escherichia coli. Transrectal ultrasonography demonstrated no evidence of abscess. Excretory urography demonstrated a persistent right nephrogram with nonvisualization of
We report
the case of a patient with acute pyelonephritis as a previously unreported complication of transrectal ultrasonographically guided biopsy of the prostate. Diagnosis was made on the basis of computed tomographic findings. CASE
REPORT
A 67-yr-old man underwent transrectal ultrasonographically guided biopsy of an incidentally discovered prostatic nodule. The patient received cephalexin (Keftab), 250 mg orally q.i.d., beginning the day before biopsy, and a Fleet enema was given the morning of biopsy. The biopsy proce:dure involved three passes with an 1s-gauge needle (Eliopty-Cut, Bard Urological, Covington, GA) mounted. on a spring-loaded biopsy device (Biopty, Bard Urological) with guidance by a 6MHz transrectal probe (Gleneral Electric Medical Systems, Milwaukee, WI). NIOimmediate complications occurred, and the patient was discharged after our standard l-h observation period. Two days after biopsy, the patient was admitted because of fever and chills. Results of blood cultures were negative. The patient was treated with ampicillin and gentamicin i.v. over 4 days, became asymptomatic, and was discharged home with instructions to take cefaclor (Ceclor), 250 mg orally t.i.d., for 3 wk. Three days after com:pletion of the course of cefaclor, the patient was readmitted because of fever Fig. 1. Abdominal film 90 min after i.v. injection of contrast medium demonstrating persistent pyelonephritis on the right with nonvisualization of the collecting system.
t Correspondence should be addressed to Carl R. Larsen, Department of Diagnostic Radiology, Lahey Clinic Medical Center, 4 1 Mall Road, Burlington, MA 01805. 297
298
Computerized Medical Imaging and Graphics
July-August/l992,
Volume 16, Number 4
Fig. 2. Selected image from CT 10 h after administration of contrast medium demonstrating patchy persistent pylonephritis on the right. The normal left kidney is completely free of contrast material.
the right upper collecting system (Fig. 1). Right-sided obstruction was initially suspected, but results of renal ultrasonography were normal, including no evidence of hydronephrosis. Computed tomography (CT) performed about 10 h after excretory urography without additional i.v. contrast medium demonstrated patchy areas of persistent opacification (Figs. 2 and 3), a pat-
tern consistent with acute pyelonephritis (1). The patient was given cefotaxime (Claforan) i.v. for 10 days, with complete resolution of symptoms. Results of follow-up CT 7 days after initial CT were normal. The patient has remained asymptomatic.
DISCUSSION
Fig. 3. Selected images from the same computed tomographic examination as in Fig. 2 showing patchy, frequently wedge-
shaped areas of persistent pyelonephritis.
Transrectal ultrasonographically guided biopsy of the prostate is associated with infrequent infectious complications, including sepsis (2-5) and orchitis (our experience). Acute pyelonephritis is a previously unreported complication associated with this procedure, although one case has been reported (6) after digitally guided transrectal biopsy of the prostate. Although the diagnosis of acute pyelonephritis is frequently made on a clinical basis, radiologic examination may be used to confirm the diagnosis, demonstrate the extent of disease, and evaluate for presence of abscess. Contrast-enhanced CT has a higher sensitivity than excretory urography, ultrasonography, or noncontrast CT in the detection of acute renal inflammation (7, 8). The findings on CT are one or several areas of relatively low enhancement that are frequently wedge-shaped and extend from the renal capsule to the collecting system (8- 12). On delayed contrast-enhanced CT (as in our patient), the pattern may be reversed with abnormal wedge-shaped areas demonstrating persistent enhancement and appearing more dense than the remainder of the parenchyma (1, 10).
US-guided biopsy of prostate. R. D. KRAUSEet al.
SUMMARY Acute pyelonephritis should be considered in the differential diagnosis of the febrile patient after biopsy. When not clinically evident, the diagnosis can be made by contrast-enhanced CT. However, when contrast medium has recently been given for excretory urography, CT should be performed initially without additional contrast medium because the areas of delayed enhancement are diagnostic and may be obscured by further administration of contrast medium. REFEJRENCES 1. Ishikawa, I.; Saito, Y.; Onouchi, Z.; Matsura, H.; Saito, T.; Suzuki,
2.
3.
4.
5.
6. 7.
M.; Futyu, Y. Delayed contrast enhancement in acute focal bacterial nephritis: CT features. J. Comput. Assist. Tomogr. 9:894897; 1985. Hodge, K.K.; McNeal, J.E..; Stamey, T.A. Ultrasound guided transrectal core biopsies of the palpably abnormal prostate. J. Urol. 142:66-70; 1989. Vallancien, G.; Prapotnich, IX Sibert, L.; Lugagne, P.M.; Veillon, B.; Brisset, J.M.; Andre-Bougaran, J. Comparison of the efficacy of digital rectal examination and transrectal ultrasonography in the diagnosis of prostatic cancer. Eur. Urol. 16:321-324; 1989. Coonec W.H.; Mosley, B.R.; Rutherford, CL., Jr.; Beard; J.H.; Pond. H.S.: Terrv. W.J.: Iael. T.C.: Kidd, D.D. Prostate cancer detection in a chnical urological practice by ultrasonography, digital rectal examination and prostate specific antigen. J. Urol. 143:1146-l 154; 1990. Devonec, M.; Fendler, J.P; Monsallier. M.; Mouriquand, P.; Maquet, J.H.; Mestas, J.L.; Dutrieux-Berger, N.; Perrin, P. The significance of the prostatic hypoechoic area: Results in 226 ultrasonically guided prostatic biopsies. J. Ural. 143:316-3 19; 1990. Fortunoff, S. Needle biopsy of the prostate: A review of 346 biopsies. J. Urol. 87:159-163; 1962. Morehouse, H.T.: Weiner, S.N.; Hoffman-Tretin, J.C. Inflammatory disease of the kidney. Semin. Ultrasound CT. MR. 7: 246-258; 1986.
299
8. Soulen, M.C.; Fishman, E.K.; Goldman, SM.; Gatewood, O.M. Bacterial renal infection: Role of CT. Radiology 171:703-707: 1989. 9. Soulen, M.C.: Fishman, E.K.; Goldman, S.M. Sequelae of acute renal infections: CT evaluation. Radioloav 173:423-426: 1989. 10. Rigsby, C.M.; Rosenfield, A.T.; Clickman, M.G.; Hodson, J. Hemorrhagic focal bacterial nephritis: Findings on gray-scale sonography and CT. AJR. 146:1173-l 177; 1986. 11. Hoffman, E.P.; Mindelzun, R.E.; Anderson, R.U. Computed tomography in acute pyelonephritis associated with diabetes. Radiology 135:691-695; 1980. 12. Gold, R.P.; McClennan, B.L.; Rottenberg, R.R. CT appearance of acute inflammatory disease of the renal interstitium. AJR. 141:343-349; 1983.
About the Author-RHETT
KRAUSEis an Imaging Fellow at Tufts New England Medical Center. Dr. Krause is a Former Resident in Radiology at the Lahey Clinic Medical Center.
About the Author-JOSEPH B. DOWDis Chairman Emeritus of the Department of Urology at the Lahey Clinic Medical Center and is past president of the American Urological Association and the Association of Clinical Urologists. R. LARSENreceived his medical degree from St. Louis University School of Medicine. He is a Radiologist at the Lahev Clinic Medical Center. Dr. Larsen is Assistant Clinical Professor Radiologyat Boston University School of Medicine and Lecturer in Radiology at Harvard Medical School. About the Author-CARL
of
About the Author-JOHN T. CUTTINO,JR. is Radiologist at the Lahey Clinic Medical Center and director of Genitourinary Radiology and member of the Society of Uroradiology. J. SCHOLZ received his medical degree from Georgetown Medical School and completed his residency in diagnostic radiology at the Lahey Clinic, where he served as Chairman of the Department of Diagnostic Radiology for 10 years. He is Head of the Section of Gastrointestinal Radiology of the Department of Diagnostic Radiology and Chairman of the Department of Education at the Lahey Clinic Medical Center. He holds teaching appointments at Harvard Medical School and Tufts Medical School. About the Author-FRANCIS
1992 Copyright8
0895-611 l/92 15.00 + .oO PressLid. 1992 Pergamon
ACUTE PYELONEPHRITIS AFTER TRANSREmAL ULTRASONOGRAPHICALLY GUIDED BIOPSY OF THE PROSTATE: :DIAGNOSIS BY COMPUTED TOMOGRAPHY
R.hett D. Krause*, Joseph B. Dowdt, Carl R. Larsen*>*, John T. Cuttino, Jr.*, and Francis J. Scholz* Departments
of *Diagnostic
Radiology
and +Urology, Lahey Clinic Medical Center, Burlington,
MA 01805
(Received I7 December 1991) Abstract-Acute pyelonephritls developed in a 67-yr-old man after transrectal ultrasonographically guided biopsy of the prostate. The clinical presentation and results of excretory urography were nondlagnostic. Diagnosis was made by computed tolmography, which was delayed 12 h after i.v. administration of contrast medium. Key Words: Acute pyelonephritis, Transrectal ultrasonographically guided biopsy, Prostate
INTROIDUCIION
(40.6’C) and rigors. On physical examination, the prostate was tender, but no tenderness was felt over the costovertebral angle. Results of blood and urine cultures were positive for Escherichia coli. Transrectal ultrasonography demonstrated no evidence of abscess. Excretory urography demonstrated a persistent right nephrogram with nonvisualization of
We report
the case of a patient with acute pyelonephritis as a previously unreported complication of transrectal ultrasonographically guided biopsy of the prostate. Diagnosis was made on the basis of computed tomographic findings. CASE
REPORT
A 67-yr-old man underwent transrectal ultrasonographically guided biopsy of an incidentally discovered prostatic nodule. The patient received cephalexin (Keftab), 250 mg orally q.i.d., beginning the day before biopsy, and a Fleet enema was given the morning of biopsy. The biopsy proce:dure involved three passes with an 1s-gauge needle (Eliopty-Cut, Bard Urological, Covington, GA) mounted. on a spring-loaded biopsy device (Biopty, Bard Urological) with guidance by a 6MHz transrectal probe (Gleneral Electric Medical Systems, Milwaukee, WI). NIOimmediate complications occurred, and the patient was discharged after our standard l-h observation period. Two days after biopsy, the patient was admitted because of fever and chills. Results of blood cultures were negative. The patient was treated with ampicillin and gentamicin i.v. over 4 days, became asymptomatic, and was discharged home with instructions to take cefaclor (Ceclor), 250 mg orally t.i.d., for 3 wk. Three days after com:pletion of the course of cefaclor, the patient was readmitted because of fever Fig. 1. Abdominal film 90 min after i.v. injection of contrast medium demonstrating persistent pyelonephritis on the right with nonvisualization of the collecting system.
t Correspondence should be addressed to Carl R. Larsen, Department of Diagnostic Radiology, Lahey Clinic Medical Center, 4 1 Mall Road, Burlington, MA 01805. 297
298
Computerized Medical Imaging and Graphics
July-August/l992,
Volume 16, Number 4
Fig. 2. Selected image from CT 10 h after administration of contrast medium demonstrating patchy persistent pylonephritis on the right. The normal left kidney is completely free of contrast material.
the right upper collecting system (Fig. 1). Right-sided obstruction was initially suspected, but results of renal ultrasonography were normal, including no evidence of hydronephrosis. Computed tomography (CT) performed about 10 h after excretory urography without additional i.v. contrast medium demonstrated patchy areas of persistent opacification (Figs. 2 and 3), a pat-
tern consistent with acute pyelonephritis (1). The patient was given cefotaxime (Claforan) i.v. for 10 days, with complete resolution of symptoms. Results of follow-up CT 7 days after initial CT were normal. The patient has remained asymptomatic.
DISCUSSION
Fig. 3. Selected images from the same computed tomographic examination as in Fig. 2 showing patchy, frequently wedge-
shaped areas of persistent pyelonephritis.
Transrectal ultrasonographically guided biopsy of the prostate is associated with infrequent infectious complications, including sepsis (2-5) and orchitis (our experience). Acute pyelonephritis is a previously unreported complication associated with this procedure, although one case has been reported (6) after digitally guided transrectal biopsy of the prostate. Although the diagnosis of acute pyelonephritis is frequently made on a clinical basis, radiologic examination may be used to confirm the diagnosis, demonstrate the extent of disease, and evaluate for presence of abscess. Contrast-enhanced CT has a higher sensitivity than excretory urography, ultrasonography, or noncontrast CT in the detection of acute renal inflammation (7, 8). The findings on CT are one or several areas of relatively low enhancement that are frequently wedge-shaped and extend from the renal capsule to the collecting system (8- 12). On delayed contrast-enhanced CT (as in our patient), the pattern may be reversed with abnormal wedge-shaped areas demonstrating persistent enhancement and appearing more dense than the remainder of the parenchyma (1, 10).
US-guided biopsy of prostate. R. D. KRAUSEet al.
SUMMARY Acute pyelonephritis should be considered in the differential diagnosis of the febrile patient after biopsy. When not clinically evident, the diagnosis can be made by contrast-enhanced CT. However, when contrast medium has recently been given for excretory urography, CT should be performed initially without additional contrast medium because the areas of delayed enhancement are diagnostic and may be obscured by further administration of contrast medium. REFEJRENCES 1. Ishikawa, I.; Saito, Y.; Onouchi, Z.; Matsura, H.; Saito, T.; Suzuki,
2.
3.
4.
5.
6. 7.
M.; Futyu, Y. Delayed contrast enhancement in acute focal bacterial nephritis: CT features. J. Comput. Assist. Tomogr. 9:894897; 1985. Hodge, K.K.; McNeal, J.E..; Stamey, T.A. Ultrasound guided transrectal core biopsies of the palpably abnormal prostate. J. Urol. 142:66-70; 1989. Vallancien, G.; Prapotnich, IX Sibert, L.; Lugagne, P.M.; Veillon, B.; Brisset, J.M.; Andre-Bougaran, J. Comparison of the efficacy of digital rectal examination and transrectal ultrasonography in the diagnosis of prostatic cancer. Eur. Urol. 16:321-324; 1989. Coonec W.H.; Mosley, B.R.; Rutherford, CL., Jr.; Beard; J.H.; Pond. H.S.: Terrv. W.J.: Iael. T.C.: Kidd, D.D. Prostate cancer detection in a chnical urological practice by ultrasonography, digital rectal examination and prostate specific antigen. J. Urol. 143:1146-l 154; 1990. Devonec, M.; Fendler, J.P; Monsallier. M.; Mouriquand, P.; Maquet, J.H.; Mestas, J.L.; Dutrieux-Berger, N.; Perrin, P. The significance of the prostatic hypoechoic area: Results in 226 ultrasonically guided prostatic biopsies. J. Ural. 143:316-3 19; 1990. Fortunoff, S. Needle biopsy of the prostate: A review of 346 biopsies. J. Urol. 87:159-163; 1962. Morehouse, H.T.: Weiner, S.N.; Hoffman-Tretin, J.C. Inflammatory disease of the kidney. Semin. Ultrasound CT. MR. 7: 246-258; 1986.
299
8. Soulen, M.C.; Fishman, E.K.; Goldman, SM.; Gatewood, O.M. Bacterial renal infection: Role of CT. Radiology 171:703-707: 1989. 9. Soulen, M.C.: Fishman, E.K.; Goldman, S.M. Sequelae of acute renal infections: CT evaluation. Radioloav 173:423-426: 1989. 10. Rigsby, C.M.; Rosenfield, A.T.; Clickman, M.G.; Hodson, J. Hemorrhagic focal bacterial nephritis: Findings on gray-scale sonography and CT. AJR. 146:1173-l 177; 1986. 11. Hoffman, E.P.; Mindelzun, R.E.; Anderson, R.U. Computed tomography in acute pyelonephritis associated with diabetes. Radiology 135:691-695; 1980. 12. Gold, R.P.; McClennan, B.L.; Rottenberg, R.R. CT appearance of acute inflammatory disease of the renal interstitium. AJR. 141:343-349; 1983.
About the Author-RHETT
KRAUSEis an Imaging Fellow at Tufts New England Medical Center. Dr. Krause is a Former Resident in Radiology at the Lahey Clinic Medical Center.
About the Author-JOSEPH B. DOWDis Chairman Emeritus of the Department of Urology at the Lahey Clinic Medical Center and is past president of the American Urological Association and the Association of Clinical Urologists. R. LARSENreceived his medical degree from St. Louis University School of Medicine. He is a Radiologist at the Lahev Clinic Medical Center. Dr. Larsen is Assistant Clinical Professor Radiologyat Boston University School of Medicine and Lecturer in Radiology at Harvard Medical School. About the Author-CARL
of
About the Author-JOHN T. CUTTINO,JR. is Radiologist at the Lahey Clinic Medical Center and director of Genitourinary Radiology and member of the Society of Uroradiology. J. SCHOLZ received his medical degree from Georgetown Medical School and completed his residency in diagnostic radiology at the Lahey Clinic, where he served as Chairman of the Department of Diagnostic Radiology for 10 years. He is Head of the Section of Gastrointestinal Radiology of the Department of Diagnostic Radiology and Chairman of the Department of Education at the Lahey Clinic Medical Center. He holds teaching appointments at Harvard Medical School and Tufts Medical School. About the Author-FRANCIS
