1980, British Journal of Radiology, 53, 504-506 Case reports Aschoff sinuses in the gall-bladder. British Journal of sinuses.

American Journal of Gastroenterology, 35, 534- Radiology, 33,496-501. 539. MEYERS, R. M., COOPER, J. H. and PADIS, N., 1970. MENDL, K., MCKAY, J. M. and TANNER, C. H., 1960. IntraSclerosing cholangitis. American Journal of Gastromural diverticulosis of the oesophagus and Rokitanskyenterology, 53, 221.
HALPERT, B., 1961. Significance of the Rokitansky-Aschoff

A case of renal carbunclethe role of radionuclides

By P. H. O'Reilly, E. W. Lupton, H. J. Testa and E. Charlton Edwards Departments of Urology and Nuclear Medicine, Manchester Royal Infirmary
INTRODUCTION

There is evidence that renal carbuncle is becoming more common (Rabinowitz 1972). Diagnosis can be difficult, and unless the condition is borne in mind, chronic cases may suppurate slowly with considerable resultant morbidity. We report here a typical longstanding case and discuss the available methods of investigation, including excretion urography, ultrasound, radionuclide scanning and computerassisted tomography.

CASE REPORT

A 19-year-old man was referred to the urology clinic with a two-month history of chronic low back pain and general malaise. Orthopaedic evaluation had revealed no musculoskeletal abnormality but he was tender in the right loin and excretion urography demonstrated enlargement, rotation and questionable displacement of the right kidney, with masking of the psoas shadow. It was unclear if the primary lesion was extrinsic or intrinsic to the kidney, but the possibility of a mass lesion was raised. Although urinalysis was normal, haematological investigation revealed a white cell count of 13.8x10 9 /L and an ESR of 65 mm/1st hour. Ultrasound gave distorted, complex echoes in an enlarged

FIG.1.

(A) "Tc m -gluconate vascular study showing avascular SOL involving upper and middle regions of right kidney. (B) Corresponding parenchymal study. 504

MAY

1980

Case reports kidney, but once again, it was impossible to ascertain if the primary lesion was intra- or extra-renal. At this stage, radionuclide scanning was performed. With the patient sitting in frontm of a gamma camera (Elscint Dymax L.F.) 10 mCi of "Tc -gluconate were injected intravenously; 50 one-second frames were collected at one-second intervals commencing five seconds after the injection and in addition, 6 X 5-second analogue pictures were acquired on the camera. Subsequent parenchymal pictures were obtained by collecting successive two-minute frames for ten minutes; simultaneous images of 400000 counts were collected at two, five and ten minutes. The resultant images clearly demonstrated an enlarged right kidney with an intra-renal spaceoccupying lesion involving it middle and upper regions (Fig. 1). The lesion was avascular and was reported as being either a cyst or an abscess. On the basis of this finding, and the clinical features, a diagnosis of renal carbuncle was made, and antibiotic therapy instituted (cloxacillin, 250 mg. six hourly). Over the next three days, the patient's condition began to deteriorate with a rising temperature, rigors and increasing tenderness in the right loin. Exploration was scheduled and, in the meantime, computer-assisted tomography confirmed the clinical impression that the carbuncle had proceeded to perinephric abscess formation. At operation, a large collection of pus was drained from the perinephric space and subsequently grew staphylococcus pyogenes. Postoperatively, the patient developed bronchopneumonia which responded to an increased dose of cloxacillin and the addition of fucidin. Subsequent radionuclide scanning showed complete resolution of the renal lesion (Fig. 2) and the patient was discharged on the 19th post-operative day. He was completely well at his subsequent out-patient review.
DISCUSSION

Renal carbuncles are generally found in young adults or debilitated patients such as diabetics or those on immunosuppresive therapy. A relationship can usually be demonstrated with distant staphylococcal infections {e.g. boils, septic fingers, chest infections), but direct spread of gram-negative organisms from the lower urinary tract is not uncommon. The condition is increasingly encountered in drug abusers, where blood-borne infection follows the use of contaminated syringes. Presentation may be acute, with loin pain, fever and septicaemia, or chronic, with malaise, weight loss and vague back painsymptoms suggestive of a malignancy. The pathogenic process involves a severe suppurative pyelonephritis, with multiple microabscesses coalescing to form the definitive lesion. It is essentially a parenchymal disease; if spread does occur, it does so by bursting through the capsule into the perinephric tissues (as in the present case), rather than tracking into the collecting system (Blandy 1976). Initial detection is usually by excretion urography, but this is non-specific, showing a lumbar scoliosis concave to the affected side, loss of the psoas shadow and a possible soft tissue mass. Arteriography may be recommended at this time, especially if a malignancy is suspected. However, it may not be helpful, for it can show an avascular lesion, abnormal vasculature or even appearances

2. (A) Post-operative "Tc m -gluconate vascular study showing complete return to normal of the right kidney. (B) Corresponding parenchymal study.
FIG.

suggesting a tumour circulation (Caplan 1967). Ultrasound may show either transonic or complex echoes (Sherwood 1975). In the present case, it failed to delineate an intra-renal lesion accurately. The radionuclide scan, however, did demonstrate a large, avascular intrarenal lesion expanding the

505

1980, British Journal of Radiology, 53, 506-508 Case reports middle and upper poles of the affected kidney, indicative of either a cyst or an abscess. Taken in the context of the patient's symptoms, this suggested a diagnosis of renal carbuncle. The CAT scan was performed at a time when the lesion had progressed to form a perinephric abscess, which it demonstrated. Had it been requested earlier, it would presumably have demonstrated that the initial lesion was intra-renal. Antibiotics are the treatment of choice for renal carbuncle with exploration only if the diagnosis is in doubt or complications ensue. The present case suggests that after urography, the simplest and most reliable procedure is radionuclide imaging. The potential of radionuclides in renal inflammatory disease has been described by Rosenthal and Reed (1968), while the technique has recently been reviewed in detail (O'Reilly et al., 1979). Certainly the sequence of clinical findings, urography and radionuclide scanning described here should alert the clinician to the diagnosis of renal carbuncle; the radionuclide procedure will be of further value in monitoring the response of the lesion to treatment. REFERENCES BLANDY, J. P., 1976. Urology. (Blackwell Scientific Publications, London).
CAPLAN, L. H., SIEGELMAN, S. S. and BOSNIAK, M. A., 1967.

Angiography in inflammatory space-occupying lesions of the kidney. Radiology, 88, 14-23.

O'REILLY, P. H., SHIELDS, R. A. and TESTA, H. J., 1979.

Nuclear Medicine in Urology and Nephrology. (Butterworths, London and Boston).

RABINOWITZ, J. G., KINKHABWALA, M. N. and ROBINSON,

T., 1972. Acute renal carbuncle. The roentgenological clarification of a medical enigma. American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 116,740-14%.
ROSENTHAL, L. and REED, E. C , 1968. Radionuclide

distinction of vascular and non-vascular lesions of the kidney. Canadian Medical Association Journal, 98, 1165. SHERWOOD, T., 1975. Renal masses and ultrasound. British Medical Journal, ii, 682-683.

Early ultrasound diagnosis of fetal bladder neck obstruction

By Pat Farrant, D.C.R.M.U. Division of Ultrasound, X-ray Department, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3U J {Received June 1979) appeared normal, but the abdominal wall seemed to be distended around the cyst, and the fetal abdominal organs, apart from the liver, were not distinguished (Fig. 2). Since the liver was displaced upwards by the cyst we thought that the cystic structure might possibly represent an obstructed fetal bladder. Three days later it was decided to perform a paracentesis under ultrasound control, and approximately 50 ml of fluid were drained from the cyst which we had calculated contained about 250 ml. The fetal heart rate was monitored throughout and remained stable. Immediately after paracentesis the fetus was again scanned, the cyst appeared smaller and was obviously arising from the pelvis. The fetus had also developed ascites, presumably due to leakage of the fluid from the cyst through the puncture site into the CASE REPORT A 30-year-old nurse gravida 1 para 0, was first seen in the peritoneal cavity (Fig. 3). Three days later, another scan was performed and showed antenatal booking clinic at 14 weeks. Four months previously she had stopped taking "the pill" as she had de- the cyst to be smaller, and the left kidney was apparently veloped hypertension. Her blood pressure on booking was normal. The right kidney was not seen. The fetus, however, 125/80. At 16 weeks her blood pressure had risen to had gross ascites and moderate hydramnios was present 1 50/94-138/98, and at home the following day it was 150/90. (Fig. 4). A later scan after another three days showed no At 16 weeks and four days the patient was admitted for change. The case was discussed with Dr. Wigglesworth from the bed rest, and her diastolic pressure remained at 90. At 17 weeks and six days she was started on methyldopa, Hammersmith Hospital, who thought there was a high and the following day attended the ultrasound department probability of fetal lung hypoplasia in association with the for a routine scan. The scan demonstrated a single fetus bladder neck obstruction. The parents finally decided to have the pregnancy lying in a breech presentation, and the BPD measurement was correct for the patient's dates. The lower part of the terminated, and at 19 weeks and six days a prostaglandin uterus was virtually filled by a single cystic structure abortion was performed (Fig. 5). The following day the 8.5 cm in diameter and only a small quantity of liquor was patient's diastolic blood pressure was 80, and at the postpresent (Fig. 1). On transverse sections the fetal chest natal clinic eight weeks later was 140/90, having also been 506 Ultrasound diagnosis of fetal urinary obstruction has previously only been achieved late in pregnancy. Garrett et al. (1975) reported the grey scale ultrasound findings in two cases at 34 and 32 weeks gestational age. In neither case were the findings of any therapeutic importance. We have recently diagnosed a case of fetal urinary obstruction in an 18week pregnancy. The ultrasound findings enabled termination of what would have been a non-viable fetus.