BILATERAL
CHRONIC
ASSOCIATED ZVI F. BRAF,
URETERITIS
WITH SERRATIA
MARCESCENS
M.D.
M. J. V. SMITH,
M.D.
From the Division of Urology, Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia
ABSTRACT - To our knowledge this is the first case of bilateral obstructive uropathy caused by nonspeci$c chronic ureteritis to be reported. Prior to operation the bilateral involvement was thought to be due to a tuberculous infection or retroperitoneal fibrosis. The diagnostic difjiculties were similar to those previously reported in the unilateral involvement. The focus of the infective organism found was Sematia marcescens which originated in the right kidney.
Intrinsic, nonspecific inflammatory lesions of the ureter are rare, and only 28 cases were rediffuse occurported in the past. l-3 Bilateral rence of this type of obstructive uropathy has not been reported before. The unusual diagnosis of bilateral ureteritis in the case reported was established at the time of operative exploration. Case Report A thirty-nine-year-old black male had a sudden onset of left posterior flank pain, radiating to the left lower quadrant, associated with nausea and vomiting which started the evening prior to his admission on October 12, 1975. Several months before his admission he was treated with analgesics for low back pain and noticed dark urine on several occasions, but these symptoms were never investigated. Mild left costovertebral angle (CVA) tenderness was elicited during physical examination. Urinalysis revealed many red blood cells. Urine culture grew Serratia marcescens sensitive only to gentamicin, and an intensive investigation of the patient disclosed no possible source of exogenous infection by this organism. Excretory urography revealed bilateral pyelocalyectasis more marked on the left than right, with delayed concentration and probable partial
44
obstruction on the left (Fig. 1A). On cystoscopy the bladder had a normal appearance. Retrograde pyelography demonstrated tortuous and kinking of both ureters with beading appearance of the left upper ureter and medial deviation on the right. The patient was started on antibiotics for his urine infection, and on isoniazid (INH) because of the positive purified protein derivative (PPD). The bilateral obstructive uropathy suggested a retroperitoneal process, and the patient was explored on October 22, 1975. The retroperitoneum was of normal appearance and consistency. The left ureter was easily dissected without any adhesions. In its proximal third the wall was thickened and irregular. The lumen was scattered with irregular ulcerated areas, and the frozen sections showed nonspecific chronic ureteritis. On the right side there were several areas of patchy stenosis in the proximal and midportion with the same intraluminal finding as on the left. The right ureter was easily dissected without adhesions. On the left side segmental ureterectomy with pyeloureterostomy over a stent and nephrostomy was done. On the right side a Davis intubated ureterotomy was done with a nephrostomy. The postoperative course was uneventful and the pullout ureterograms and nephrostograms were satisfactory. Urine cultures were negative at the time of discharge.
UROLOGY
/ JULY 1977 / VOLUME
X, NUMBER
1
FIGURE 1. (A)Excretory urogram after three hours clearly demonstrates ureteral compression and medical deviation. (B) Tomographic cut from excretory urogram obtained during third admission demonstrating radioLent abscess cavity. (C) Excretory urogram six weeks after unroofing cyst demonstrates prompt excretion and equal drainage.
The pathology report was the same as the frozen section. There was no evidence of granuloma or neoplasm. The patient was readmitted three weeks after his discharge because of right flank pain, nausea, and vomiting. On physical exaination there was marked tenderness in the right CVA. The white count was 12,100 (polymorphonuclears 73, bands 1, lymphocytes 23, and monocytes 3 per cent). Intravenous pyelogram showed prompt bilateral visualization and marked improvement in the upper tracts and ureters in comparison to that seen prior to surgery. There was a suggestion of an upper pole mass on the right which on review of pre-
UROLOGY
/ JULY1977 / VOLUMEX,
NUMBER1
vious films might have been present before. Urine cultures again grew S. marcescens. The temperature began to spike to 101.8” F. Appropriate antibiotic therapy was started. Arteriogram demonstrated an avascular right renal mass which was aspirated under fluoroscopy, and the patient underwent drainage of the right renal abscess. The cultures from the pus grew S. marcescens. Acid-fast bacilli and fungi were negative. The patient was discharged on tetracycline 250 mg. four times a day to be followed up. In repeated urine examinations there were 20 to 30 white blood cells per high-powered field, but the urine cultures were negative. Five
45
months later he noticed brownish urethral discharge and was subsequently hospitalized because of left epididymitis. The urine cultures again grew S. marcescens. Antibiotic therapy with gentamicin was started. Intravenous pyelogram again demonstrated a large upper pole mass on the right (Fig. 1B). Sonography confirmed this to be a mixed mass with internal ethos, and a renal abscess was strongly suspected. Therefore the patient underwent reexploration of the right flank. There was a cystic mass on the posterosuperior aspect of the right kidney from which pus was aspirated. The abscess cavity was then opened, irrigated, and unroofed. Pathologic finding on examination of the wall was that of a cyst. The pus cultured from the abscess cavity grew S. marcescens. Cultures for acid-fast bacilli and fungi were negative. The postoperative course was uneventful. The patient was discharged on minocycline (Minocin) 100 mg. twice a day. Follow-up urine cultures showed no growth. Follow-up excretory urogram showed prompt excretion and good drainage throughout the ureters (Fig. 1C). Comment A great variety of retroperitoneal processes might be responsible for unilateral or bilateral ureteral obstruction and were recently reviewed by Ross and Prout.4 Chronic ureteritis in the past was reported as a cause of unilateral segmental ureteral obstruction. The pathogenesis of this disorder is not known, but a number of the cases reported were associated with calculi or with previous urologic disease on the side of the affected ureter.2-3 In the case presented the possible focus of infection in the right renal cyst was overlooked on the first admission because of the striking bilateral ureteral obstructive picture. The spread of infection was probably through the free cross communications between the lymph channels of the opposite sides. This communication is in both directions and at all levels from the bifurcation of the aorta.5 The clinical presentation was very similar to tuberculous infection because of the intravenous pyelogram and the positive PPD. Other retroperitoneal processes causing bilateral ureteral
46
obstruction were considered in the differential diagnosis but were not found. In this case, as in all the unilateral cases, the diagnosis was established at surgical exploration and confirmed by histologic examination. The frozen section biopsy which is recommended was mandatory for the establishment of the pathologic diagnosis and the length of the ureteral inflammatory involvement. The natural habitat of S. marcescens are soil and water sources. The infection is usually transmitted from patient to patient through the hands of personnel. Almost all the patients with this infection have had catheterization or instrumentation, and about two-thirds will have an indwelling catheter. Over three-quarters have received antimicrobials to which the organism is resistant (ampicillin, penicillin, cephalothin, colistin, nitrofurantoin). 6 All these previously reported predisposing factors were not present in the case presented. It appears that the organism is able to cause a strange clinical picture mimicking a great variety of pathologic conditions. It should be considered in urologic practice whenever there is a clinical picture of a chronic inflammatory process for which the usual causes have been excluded. Richmond, Virginia 23298 (DR. BRAF) References 1.
2. 3
4.
5.
6.
MININBERG, D. T., ANDRONACO, J., NESBIT, R. M., and NAGAMATSU, G. R.: Nonspecific regional ureteritis, J. Urol. 98: 664 (1967). DAHL, D. S.: Segmental ureteritis: a report of 4 surgical cases, ibid. 105: 642 (1971). BOPP, G., and ~IULLEH-~IAHIENBERG, H. W. L.: Harnleiterstenose hei Chronischer Periureteritis und Ureteritis, Urol. Int. 29: 08 (1974). ROSS, J. S., and PROUT, G. R.: Retroperitoneal fat necrosis producing ureteral obstruction, J. Urol. 115: 524 (1976). E~~METT, J. L., and WITTEN, D. MM.: Clinical Urography, Philadelphia, W. B. Saunders Co., 1974, vol. 3. p. 2020. VON GRAEVENITZ, il. : Urinary tract infection clue to Serratia marcescens, in Urbascheks, M. D., Ed.: Gram-Negative Bacterial Infections and Mode of Endotoxin .4ctions, Berlin, Springer-Verlag, 1975, p, 32-33.
UROLOGY
/ JULY 1977 /
VOLUME X. NUMBER 1
CHRONIC
ASSOCIATED ZVI F. BRAF,
URETERITIS
WITH SERRATIA
MARCESCENS
M.D.
M. J. V. SMITH,
M.D.
From the Division of Urology, Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia
ABSTRACT - To our knowledge this is the first case of bilateral obstructive uropathy caused by nonspeci$c chronic ureteritis to be reported. Prior to operation the bilateral involvement was thought to be due to a tuberculous infection or retroperitoneal fibrosis. The diagnostic difjiculties were similar to those previously reported in the unilateral involvement. The focus of the infective organism found was Sematia marcescens which originated in the right kidney.
Intrinsic, nonspecific inflammatory lesions of the ureter are rare, and only 28 cases were rediffuse occurported in the past. l-3 Bilateral rence of this type of obstructive uropathy has not been reported before. The unusual diagnosis of bilateral ureteritis in the case reported was established at the time of operative exploration. Case Report A thirty-nine-year-old black male had a sudden onset of left posterior flank pain, radiating to the left lower quadrant, associated with nausea and vomiting which started the evening prior to his admission on October 12, 1975. Several months before his admission he was treated with analgesics for low back pain and noticed dark urine on several occasions, but these symptoms were never investigated. Mild left costovertebral angle (CVA) tenderness was elicited during physical examination. Urinalysis revealed many red blood cells. Urine culture grew Serratia marcescens sensitive only to gentamicin, and an intensive investigation of the patient disclosed no possible source of exogenous infection by this organism. Excretory urography revealed bilateral pyelocalyectasis more marked on the left than right, with delayed concentration and probable partial
44
obstruction on the left (Fig. 1A). On cystoscopy the bladder had a normal appearance. Retrograde pyelography demonstrated tortuous and kinking of both ureters with beading appearance of the left upper ureter and medial deviation on the right. The patient was started on antibiotics for his urine infection, and on isoniazid (INH) because of the positive purified protein derivative (PPD). The bilateral obstructive uropathy suggested a retroperitoneal process, and the patient was explored on October 22, 1975. The retroperitoneum was of normal appearance and consistency. The left ureter was easily dissected without any adhesions. In its proximal third the wall was thickened and irregular. The lumen was scattered with irregular ulcerated areas, and the frozen sections showed nonspecific chronic ureteritis. On the right side there were several areas of patchy stenosis in the proximal and midportion with the same intraluminal finding as on the left. The right ureter was easily dissected without adhesions. On the left side segmental ureterectomy with pyeloureterostomy over a stent and nephrostomy was done. On the right side a Davis intubated ureterotomy was done with a nephrostomy. The postoperative course was uneventful and the pullout ureterograms and nephrostograms were satisfactory. Urine cultures were negative at the time of discharge.
UROLOGY
/ JULY 1977 / VOLUME
X, NUMBER
1
FIGURE 1. (A)Excretory urogram after three hours clearly demonstrates ureteral compression and medical deviation. (B) Tomographic cut from excretory urogram obtained during third admission demonstrating radioLent abscess cavity. (C) Excretory urogram six weeks after unroofing cyst demonstrates prompt excretion and equal drainage.
The pathology report was the same as the frozen section. There was no evidence of granuloma or neoplasm. The patient was readmitted three weeks after his discharge because of right flank pain, nausea, and vomiting. On physical exaination there was marked tenderness in the right CVA. The white count was 12,100 (polymorphonuclears 73, bands 1, lymphocytes 23, and monocytes 3 per cent). Intravenous pyelogram showed prompt bilateral visualization and marked improvement in the upper tracts and ureters in comparison to that seen prior to surgery. There was a suggestion of an upper pole mass on the right which on review of pre-
UROLOGY
/ JULY1977 / VOLUMEX,
NUMBER1
vious films might have been present before. Urine cultures again grew S. marcescens. The temperature began to spike to 101.8” F. Appropriate antibiotic therapy was started. Arteriogram demonstrated an avascular right renal mass which was aspirated under fluoroscopy, and the patient underwent drainage of the right renal abscess. The cultures from the pus grew S. marcescens. Acid-fast bacilli and fungi were negative. The patient was discharged on tetracycline 250 mg. four times a day to be followed up. In repeated urine examinations there were 20 to 30 white blood cells per high-powered field, but the urine cultures were negative. Five
45
months later he noticed brownish urethral discharge and was subsequently hospitalized because of left epididymitis. The urine cultures again grew S. marcescens. Antibiotic therapy with gentamicin was started. Intravenous pyelogram again demonstrated a large upper pole mass on the right (Fig. 1B). Sonography confirmed this to be a mixed mass with internal ethos, and a renal abscess was strongly suspected. Therefore the patient underwent reexploration of the right flank. There was a cystic mass on the posterosuperior aspect of the right kidney from which pus was aspirated. The abscess cavity was then opened, irrigated, and unroofed. Pathologic finding on examination of the wall was that of a cyst. The pus cultured from the abscess cavity grew S. marcescens. Cultures for acid-fast bacilli and fungi were negative. The postoperative course was uneventful. The patient was discharged on minocycline (Minocin) 100 mg. twice a day. Follow-up urine cultures showed no growth. Follow-up excretory urogram showed prompt excretion and good drainage throughout the ureters (Fig. 1C). Comment A great variety of retroperitoneal processes might be responsible for unilateral or bilateral ureteral obstruction and were recently reviewed by Ross and Prout.4 Chronic ureteritis in the past was reported as a cause of unilateral segmental ureteral obstruction. The pathogenesis of this disorder is not known, but a number of the cases reported were associated with calculi or with previous urologic disease on the side of the affected ureter.2-3 In the case presented the possible focus of infection in the right renal cyst was overlooked on the first admission because of the striking bilateral ureteral obstructive picture. The spread of infection was probably through the free cross communications between the lymph channels of the opposite sides. This communication is in both directions and at all levels from the bifurcation of the aorta.5 The clinical presentation was very similar to tuberculous infection because of the intravenous pyelogram and the positive PPD. Other retroperitoneal processes causing bilateral ureteral
46
obstruction were considered in the differential diagnosis but were not found. In this case, as in all the unilateral cases, the diagnosis was established at surgical exploration and confirmed by histologic examination. The frozen section biopsy which is recommended was mandatory for the establishment of the pathologic diagnosis and the length of the ureteral inflammatory involvement. The natural habitat of S. marcescens are soil and water sources. The infection is usually transmitted from patient to patient through the hands of personnel. Almost all the patients with this infection have had catheterization or instrumentation, and about two-thirds will have an indwelling catheter. Over three-quarters have received antimicrobials to which the organism is resistant (ampicillin, penicillin, cephalothin, colistin, nitrofurantoin). 6 All these previously reported predisposing factors were not present in the case presented. It appears that the organism is able to cause a strange clinical picture mimicking a great variety of pathologic conditions. It should be considered in urologic practice whenever there is a clinical picture of a chronic inflammatory process for which the usual causes have been excluded. Richmond, Virginia 23298 (DR. BRAF) References 1.
2. 3
4.
5.
6.
MININBERG, D. T., ANDRONACO, J., NESBIT, R. M., and NAGAMATSU, G. R.: Nonspecific regional ureteritis, J. Urol. 98: 664 (1967). DAHL, D. S.: Segmental ureteritis: a report of 4 surgical cases, ibid. 105: 642 (1971). BOPP, G., and ~IULLEH-~IAHIENBERG, H. W. L.: Harnleiterstenose hei Chronischer Periureteritis und Ureteritis, Urol. Int. 29: 08 (1974). ROSS, J. S., and PROUT, G. R.: Retroperitoneal fat necrosis producing ureteral obstruction, J. Urol. 115: 524 (1976). E~~METT, J. L., and WITTEN, D. MM.: Clinical Urography, Philadelphia, W. B. Saunders Co., 1974, vol. 3. p. 2020. VON GRAEVENITZ, il. : Urinary tract infection clue to Serratia marcescens, in Urbascheks, M. D., Ed.: Gram-Negative Bacterial Infections and Mode of Endotoxin .4ctions, Berlin, Springer-Verlag, 1975, p, 32-33.
UROLOGY
/ JULY 1977 /
VOLUME X. NUMBER 1
