448

BRITISH JOURNAL OF UROLOGY

first to report milk of calcium in a renal cyst. It probably forms because of incomplete egress of urine from an enclosed space. Usually asymptomatic, on a supine radiograph of the abdomen it appears as a faintly opaque density, often granular, with blurring or thinness of the calcification along the margins (Murray, 1971). The demonstration of a half-moon shaped opacity on erect or lateral decubitus roentgenograms is a diagnostic sign. On routine sonography, differentiation from calculus is difficult, but gravity-dependent sonography is the most sensitive method of diagnosis (Patriquin et al., 1985). No treatment is indicated unless the condition is complicated by calculus formation or infection. We suggest that a high degree of radiological suspicion on KUB can help in the diagnosis of this uncommon but important entity, thereby avoiding unwarranted ESWL therapy.

References Fig. Erect film showing the change in the shape of the densities with characteristic “half-moon”configuration indicative of fluid levels.

Case Report A 43-year-old asymptomatic female with a past history of right ureterolithotomy and left pyelolithotomy presented with a plain X-ray of the kidneys, ureter and bladder (KUB) revealing 3 calcific shadows over the left renal area. Intravenous urography confirmed that the calcific densities were within the dilated lower calyx. Diuretic renography demonstrated a non-obstructive pelviureteric junction. ESWL with a double pigtail stent was performed on a Siemen’s Lithostar. The posttreatment K U B revealed no fragmentation but a change in the shape and size of the densities. ESWL was repeated 48 h later and the subsequent K U B showed only a single density without disintegration. ESWL was repeated 7 days later and the K U B again revealed 3 densities with no evidence of fragmentation. A critical review of the previous K U B films suggested changing shape, size and number of the densities but no fragmentation. An upright X-ray of the abdomen showed multifile fluid levels with a half-moon appearance which is diagnostic of renal milk of calcium. Sonography confirmed the postural movement of the opacities.

Comment Milk of calcium is a semi-solid precipitate of calcium salts. It occurs occasionally in the biliary tract, less commonly in the urinary tract and rarely in the bronchogenic cyst. Howell (1959) was the

Howell, R. D. (1959). Milk of calcium renal stone. J . Urol., 82, 197-1 99. Murray, R. L. (1971). Milk of calcium in the kidney: diagnostic features on vertical beam roentgenograms. A.J.R., 113,455459. Patriquin, H., Lafortune, M. and Filiatrault, D. (1985). Urinary milk of calcium in children and adults: use of gravity dependent sonography. A . J . R . ,144,407413. Requests for reprints to: C. S. Biyani, D/49 Pamposh Enclave, Greater Kailash I, New Delhi 110 048, India.

Systemic Candidiasis caused by a Renal Transplant Ureteric Stent M. L. NICHOLSON, P. S. VEITCH, P. K. DONNELLY and P. R. F. BELL, Transplant Unit, Leicester General Hospital, Leicester

Double J stents have been associated with infective complications and although these have been well documented for the native ureter (Pocock et al., 1986; Smedley et al., 1988), little attention has been paid to the use of these devices in renal transplantation. In this situation the use of prolonged immunosuppression may lead to an increased risk of infective complications.

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CASE REPORTS

Case Report A 53-year-old woman underwent cadaveric renal transplantation under immunosuppression with cyclosporin A and high dose steroids. Two months after transplantation the serum creatinine increased rapidly from a baseline of 21 1 pmol/l to a peak of 655 pmol/l and a transplant biopsy confirmed acute cellular rejection. This was treated with 3 daily doses of 0.5 g methylprednisolone given intravenously. At the same time the patient developed severe suprapubic pain and an antegrade pyelogram demonstrated a urinary leak at the vesicoureteric junction. This was treated by early exploration and the insertion of a double J stent (Surgitek, Wisconsin, USA). Further antirejection therapy proved necessary and a 10-day course of the monoclonal antibody OKT3 was administered. Ten weeks later routine urine culture yielded a heavy growth of Candida albicans and the ureteric stent was removed immediately using a flexible cystoscope. The patient subsequently complained of blurred vision and ophthalmoscopy revealed the presence of fungal balls in the right retina. A course of intravenous and intravitreous amphotericin B was successful but the patient sustained a marked loss of visual acuity in the right eye. It is suggested that whenever ureteric stents are used in renal transplantation they should be removed early in order to avoid infective complications.

Fig. Immediate antegrade nephrostogram showing obstructing filling defect in the renal pelvis, appearances consistent with clot.

References Pocock, R. D., Stower, M. J., Ferro, M. A. et al. (1978). Double J stents: a review of 100 patients. Br. J . Urol., 58,629-633. Smedley, F. H., Rimmer, J., Taube, M. etal. (1988). 168 double J (pigtail) ureteric catheter insertions: a retrospective review. Ann R. CON.Surg. Engl., 70,311-319. Requests for reprints to: M. L. Nicholson, Department of Surgery, E Floor West Block, University Hospital, Queen’s Medical Centre, Nottingham N G l 2 U H .

Profound Haemorrhage causing Acute Obstruction in Medullary Sponge Kidney C. D. B E T S and P. H. O’REILLY, Department of Urology, Stepping Hill Hospital, Stockport

sponge kidneys (MSK). On admission she was tender in the left loin but apyrexial. Over the following 24 h she became increasingly unwell; she developed a pyrexia, severe left loin pain and increasing haematuria which required transfusion. A significant Escherichia coIi urinary infection was found. Intravenous urography demonstrated marked delay in the elimination of contrast from the left kidney, with a dilated pelvicaliceal system. Parenteral antibiotics were commenced and under local anaesthesia a 7 F percutaneous pigtail catheter was inserted, with initial drainage of blood. The immediate antegrade nephrostogram demonstrated a filling defect at the pelviureteric junction and upper ureter (Fig.) The patient’s condition improved and on the following day a 9.5 F rigid ureteroscope was passed up the left ureter. This revealed a large clot in the renal pelvis. Agitation with a guide wire broke up the clot, which was then flushed out through the nephrostomy tube by the ureteroscopic irrigant. The patient made a full recovery and a further nephrostogram demonstrated free flow of contrast down the ureter. Blood clotting studies were normal.

Case Report

Comment

A 45-year-old woman was admitted with a 2-week history of persistent haematuria. She had suffered 2 previous episodes of haematuria and an intravenous urogram had demonstrated the typical features of bilateral medullary

Although medullary sponge kidney is usually regarded as a relatively benign congenital condition, the prognosis is poor in 10% of patients. The condition is usually bilateral and renal failure may

Systemic candidiasis caused by a renal transplant ureteric stent.

448 BRITISH JOURNAL OF UROLOGY first to report milk of calcium in a renal cyst. It probably forms because of incomplete egress of urine from an encl...
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