1977, British Journal of Radiology, 50, 438-440 Case reports

Before the use of modern antibiotics the mortality was between 22 and 31%, usually related to toxaemia (Mansfield, 1945). Deaths are now rare. The gangrenous process is usually limited to the scrotum but may spread under Collier's and Scarpa's fascia into the abdomen (Campbell and Harrison, 1970). It rarely involves the vas deferens or testes. The radiological findings are those of marked swelling of the scrotal tissues together with air densities in the interstices of the scrotum. These findings must be distinguished from other causes of pneumoscrotum, including gangrene of a known aetiology, injury to the urethra or scrotum after trauma, and anastomotic leakage after anterior resection of the colon (Castellano et al., 1973). It must be distinguished radiographically from herniation of bowel loops into a scrotal sac. Fournier's gangrene may be related to an underlying antecedent cause. Diabetes, alcoholism and general debility have been implicated. In our patient diabetes mellitus may have played an important part in the development of the inflammatory process.

An alternative explanation for the condition is vascular thrombosis related to infection and analogous to cavernous sinus thrombosis. The infections may be due to organisms entering the skin through minute abrasions or embolic bacteria from remote sites. Most cases present with pneumoscrotum and gas is often encountered on surgical incision. The bacteriology of Fournier's gangrene is incompletely understood but anaerobic streptococcus has been the most frequently found organism. REFERENCES BURPEE, J., and EDWARD, P., 1972. Fournier's gangrene.

Journal of Urology, 107, 812-814. CAMPBELL, M., and HARRISON, J. H., 1970. Urology, 3rd

edition (William B. Saunders Company, Philadelphia, Pa.). CASTELLANO, S. R., REGE, P., and EVANS, A., 1973. Pneumo-

scrotum: a case report and review of the literature. The Journal of Urology, 110, 225-226. MANSFIELD, O. T., 1945. Spontaneous gangrene of the scrotum (Fournier's gangrene). British Journal of Surgery, 33, 275-277. SOONG, C. L., and WHEE, L. K., 1966. Scrotal gangrene in a

four-month-old infant. Singapore Medical Journal, 7,

Gas nephrogram: an unusual complication of renal transplantation R. Parameswaran, M.B., B.S., M.D., and T. Feest, M.A., M.B., B.Chir., M.R.C.P. Departments of Radiology and Medicine, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP (Received December, 1976)

The major complications following renal transplantation often call for selective angiography, venography and ultrasonic examination (especially of a palpable mass at the site of transplant). Functional status can be assessed by an intravenous excretion urogram or isotope renogram. We present an unusual plain film diagnosis.

further methylprednisolne serum creatinine stabilized at 600 /xmol/1. A transplant biopsy was performed and this showed some necrosis of the renal parenchyma; in view of the residual renal function this was presumed to be patchy. The kidney at that time did not appear enlarged or tender, but after two weeks a palpable perinephric mass developed over the upper pole. Attempted aspiration brought out some gas. To exclude accidental perforation of the colon radiography of the abdomen was carried out.

Radiographic findings The transplant kidney was very well demonstrated by A woman aged 53 years had a well-matched cadaver inherent contrast due to collections of gas within the necrotic kidney transplanted into the left iliac fossa in July 1975, renal parenchyma. There was a cavity adjacent to the upper following two months of maintenance dialysis for renal pole, which showed a gas/fluid level on the radiograph in failure caused by rapidly progressive glomerulonephritis. the erect position. A diagnosis of transplant sepsis with Two early rejection episodes were treated with methylpred- localized abscess formation was made. An I.V.P. only showed nisolone, and maintenance was with prednisone and poor excretion in her own kidneys. azathioprine. She developed insulin dependent diabetes, At transplant nephrectomy a totally infected necrotic and for five days after discharge had a mild leucopenia. She kidney was removed. A radiograph of the excised kidney was discharged after four weeks with a serum creatinine confirmed the presence of gas in the renal parenchyma, and level of 336 /xmol/1. histological examination showed gram negative bacilli. A One week later she was re-admitted with staphylococcal wound infection by pseudomonas and proteus organisms skin sepsis and deteriorating renal function. Following followed but slowly recovered. CASE HISTORY

438

JUNE 1977

Case reports 1. Erect radiograph of the abdomen showing the transplant kidney clearly outlined by gas in the renal parenchyma (black arrows). Gas and fluid level in the perinephric abscess (white arrows) near the upper pole of the kidney. Several fluid levels are shown in the large bowel. FIG.

FIG. 3. Radiograph of the excised transplant kidney showing parenchymal collections of gas.

2. Enlarged view of the gas filled transplant kidney (black arrows) and the abscess (white arrows) in supine position.

FIG.

1977, British Journal of Radiology, 50, 440-443

Case reports DISCUSSION

Sepsis in various forms is still considered as an important and common complication of renal transplantation. Several reports concerning wound infections and sepsis after renal transplantation have appeared in the medical press recently, and a detailed analysis of 27 cases with wound infection and subsequent sepsis has been reported by Kyriakides et al. (1975). In 24 cases of perinephric abscess after cadaver kidney transplantation the highest incidence was in diabetic patients between 3rd and 4th decades of age. Almost half of the infected wounds had developed a haematoma which required drainage following surgery. All cases with deep infection had either a leak or a perinephric haematoma. Gram negative organisms were isolated from all cases, and in 50% E. coli was the dominant organism; 55% of cases required transplant nephrectomy. In a report from Denmark (Walter et al., 1975) indwelling drainage tubes were believed to be

the cause of wound infection in 18 out of 53 cases. The inherent contrast contributed by the presence of gas within the kidney and the fluid level in a cavity outside the kidney helped in the diagnosis of our case. The pattern of collection of intrarenal gas clearly outlined the entire kidney. Differentiation from a loop of colon filled with gas and faecal matter could be difficult unless the collection of gas outlines the whole of the kidney giving it the appearance shown in our case. Individual radiological demonstration of colon and kidney should settle the diagnosis in difficult cases. REFERENCES KYRIAKIDES, G. K., SIMMONS, R. L., and NAJARIAN, J. S.,

1975. Wound infection in renal transplantation wounds: pathogenic and prognostic factors. Annals of Surgery, 182, WALTER, S., PEDERSEN, FRITZ B. and VEJLSGAARD, R., 1975.

Urinary tract infection and wound infection in kidney transplant patients. British Journal of Urology, 47, 513-

Unusual presentation of non-parasitic hepatic cyst By Thin Thin Aye, B.Sc, M.B., B.S., DM.R.D., F.R.C.R., Radiology Department, Coventry and Warwickshire^Hospital, Coventry and J. H. Middlemiss, C.M.G., M.D., F.R.C.P., F.R.C.S., F.R.C.R. Radiology Department, University of Bristol, Bristol (Received October, 1976 and in revised form February, 1977)

Large non-parasitic hepatic cysts are rare. It is rarer size to cause symptoms. The lesion may occur still for them to show radiologically as avascular at any age. Most patients described in the literature areas, surrounded by dense curvilinear shadows on have been in the fourth or fifth decades. Females urography and for the diagnosis to be made before are affected more frequently than males. The ratio operation. A "halo" sign shown during urography is three or four to one (Caplan and Simon, 1966). has not previously been described. The right lobe is involved approximately twice Liver cysts may have their origin from aberrant as often as the left (Geist, 1955). They are frequently bile ducts in the liver; these ducts represent embry- associated with polycystic disease of the kidney and onal rests and have been found only in cystic livers occasionally are accompanied by cysts in the pancreas or livers associated with cystic kidneys. They may and spleen (Comfort et al., 1952; Deutsch, 1953). assume two forms, one arising from inflammatory Liver cysts rarely cause symptoms and are comhyperplasia of their ducts and the other by retention patible with life. Occasionally patients with liver of fluid in these ducts or as the result of congenital cysts may present with pain, pyrexia (Davis, 1936), obstruction. They are subcapsular and are filled symptoms due to pressure on the surrounding strucwith watery fluid containing albumin, mucin, choles- tures (Stock, 1952), associated cholecystitis (Deutsch, terol, epithelium and granular debris. Bile-pigment 1953), cholelithiasis (Henson et al, 1956) or jaundice is generally absent (Boyd, 1913). Alternatively the (Henson, 1963; Dardik et al, 1964). fluid may be thick bile, blood or pus (Henson If the cysts are large enough they may displace the et al., 1956). Simple cysts rarely reach sufficient right kidney medially (Geist, 1955), or the left 440

Gas nephrogram: an unusual complication of renal transplantation.

1977, British Journal of Radiology, 50, 438-440 Case reports Before the use of modern antibiotics the mortality was between 22 and 31%, usually relat...
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