BJU International (2000), 86 Suppl.
1, 70±79
Imaging in acute renal infection
A . K A W AS H I M A * { , C. M . SA N D L E R * { { and S . M . G O LD M A N* {
Departments of *Radiology and {Urology, The University of Texas-Houston Medical School, and {Department of Radiology,
Lyndon B. Johnson General Hospital, Houston, Texas, USA
Introduction
The urinary tract is one of the most common sites of
infection in humans. Acute pyelonephritis in children
usually occurs because of UTI associated with VUR, while
in adults, frank re¯ux is rarely detected. Women of
< 50 years of age are more commonly affected by acute
pyelonephritis than men. When older than this, the
incidence of UTI in men increases as a result of urinary
stasis secondary to prostatic hyperplasia and other
factors [1,2].
Acute pyelonephritis is a bacterial infection of the
kidney that causes a tubulo-interstitial in¯ammation of
the renal parenchyma. Acute renal infection is of vary-
ing severity, from uncomplicated acute pyelonephritis
through progressively worsening stages of interstitial
in¯ammation to frank abscess formation [3,4]. Because
histological specimens are dif®cult to obtain, exact
clinical correlation with these various stages of in¯am-
mation is impossible. Therefore, the primary goal of renal
imaging is to provide information about the nature and
extent of the disease and to identify signi®cant complica-
tions, e.g. gas-forming infection, abscess and urinary
obstruction [2,3,5±15].
This article presents a review of the current role of and
controversies in imaging the kidneys to evaluate patients
with acute renal infection. The nomenclature in describ-
ing the extent of the renal imaging ®ndings in acute
pyelonephritis suggested by Talner et al. is used, as
described below [2].
Radiological terminology in acute renal
infection
Previously there has been much confusion about the
terminology used to describe the extent and severity of
acute pyelonephritis. Classi®cations used by radiologists
were based solely on the radiological features with no
histological con®rmation. The advanced generalized form
of acute pyelonephritis in diabetic patients, usually with a
nonfunctioning kidney on excretory urography, was
originally described as acute bacterial pyelonephritis
[16]. The localized form of acute pyelonephritis resulting
in a mass effect on imaging studies was described with a
variety of terms, including acute focal pyelonephritis,
70
acute focal bacterial nephritis and acute lobar nephronia
[17,18]. In addition, with the advent of CT and
ultrasonography (US), subtle abnormal nephrographic
®ndings were present and variably termed cellulitis,
carbuncle, renal phlegmon, etc. [2,5]. To simplify the
terminology, Talner et al. [2] recommended that all
parenchymal abnormalities with no abscess attributable
to acute infection be called acute pyelonephritis and that
the extent or degree of involvement should be described
by one or more of the following modi®ers; (i) unilateral or
bilateral, (ii) focal or diffuse, (iii) focal swelling or no
focal swelling, and (iv) renal enlargement or no focal
enlargement. This classi®cation is used in the remainder
of this article.
Renal imaging in acute renal infection
Acute pyelonephritis in the adult
In most cases, UTI can be diagnosed in adults from the
clinical and laboratory ®ndings, and imaging is usually
unnecessary. However, imaging is indicated when adult
patients with UTI respond poorly to appropriate antibiotic
therapy after 3 days [7,13,14,19]. In addition, when a
de®nite diagnosis of acute renal infection is not
established or when patients present with recurrent
episodes of infection, renal imaging is indicated because
there is more likelihood of stones, obstruction, abscess, or
a congenital anomaly. Among patients who have a
history of poorly controlled diabetes mellitus, AIDS, renal
transplantation, or other immunocompromised disease
states, there is an increased risk of developing a
complicated UTI, including a renal or perinephric
abscess. Therefore, imaging may be required when
such patients present initially [8±10,20,21].
CT is currently considered to be better than excretory
urography [22] and US [6,7,14] in detecting the
parenchymal abnormalities caused by renal infection
and in delineating the extent of the disease. Unenhanced
CT is useful in detecting calculi, gas-forming infections,
haemorrhage [23], parenchymal calci®cations, obstruc-
tion and in¯ammatory masses. A contrast-enhanced
study is essential to completely evaluate patients with
renal in¯ammatory disease, to de®ne changes in the
renal excretion of the contrast material which occur as a
# 2000 BJU International
 IMAGING IN ACUTE RENAL INFECTION 71

result of the in¯ammation. The most common CT

®ndings are ill-de®ned wedge-shaped lesions of decreased
attenuation radiating from the papilla in the medulla
to the cortical surface, with or without swelling.
Occasionally, linear bands of alternating hyper- and
hypo-attenuation orientated parallel to the axes of the
tubules and collecting ducts are seen. These CT ®ndings
have been attributed to diminished concentration of
contrast material in the tubules caused by tubular
obstruction with in¯ammatory cells and debris, ischae-
mia and interstitial oedema [2,24±26]. Small low-density
zones arising from tissue breakdown may resolve with
treatment or may coalesce to form a frank abscess.
With the introduction of the helical (or spiral) fast-
scanning technology, a particular phase of contrast
a
medium excretion can be imaged [27]. Renal vascularity
is evaluated during the vascular phase, 10±15 s after the
initiation of intravenous (IV) contrast-medium adminis-
tration. A dense cortical nephrogram with cortico-
medullary differentiation is obtained during the
corticomedullary differentiation nephrographic phase,
20±45 s after beginning the IV injection with contrast
medium. A homogeneous nephrogram can be obtained
during the generalized homogeneous nephrographic
phase 45±120 s after IV contrast medium administra-
tion. Contrast material starts to appear in the collecting
system in the excretory phase, >2 min after adminis-
tering contrast medium [8]. Routine helical CT of the
abdomen usually involves a monophasic examination
performed either during the corticomedullary differentia-
tion or generalized homogeneous nephrographic phase. b
Enhanced helical scans obtained during the corticome-
dullary differentiation and early generalized homoge-
neous nephrographic phase may show lobar or sublobar
areas of hypo-attenuating cortex with ill-de®ned corti-
comedullary differentiation [8±10]. Nephrographic
abnormalities of acute pyelonephritis are best seen on
CT scans obtained during the generalized homogeneous
nephrographic phase (Fig. 1) [28,29]. Excretory-phase
studies are less equivocal for diagnosing renal abscesses
than scans taken soon after contrast medium injection,
when false-positive cases may occur [29]. Contrast
material in the collecting system during the excretory-
phase study can give a false impression of an abnormal
nephrogram from streak artefacts, particularly when
using non-ionic contrast material [30]. If helical CT is
available, at least the generalized nephrographic and c
excretory phase studies should be performed [29].
Fig. 1. Acute pyelonephritis in a 31-year-old woman. a, Contrast
However, the excretory phase alone is adequate for material-enhanced helical CT scan obtained during the early
management purposes and in institutions where helical corticomedullary differentiation phase reveals a focal cortical area
CT is unavailable. of minimally decreased attenuation in the upper pole of the left
Sometimes a further delayed CT scan is helpful in kidney with outer bulging (arrow). b, A CT scan obtained during the
generalized homogeneous nephrographic phase shows a focal area
differentiating tumour from an in¯ammatory mass. In
of diminished contrast enhancement extending from the medulla to
this situation, delayed CT studies may show persistent the cortex (arrow). c, The lesion becomes well de®ned on the
excretory phase scan.
# 2000 BJU International, 86 Suppl. 1, 70±79
72 A. KAWASHIMA et al.
contrast enhancement in areas where there was
previously diminished enhancement after contrast
medium [31]. Delayed CT obtained o3 h after IV
contrast medium administration has been reported to
be more useful in evaluating the extent of infection than
are early phase scans [32,33]. Three patterns of delayed
contrast staining have been described: (i) a nephrogram
replacing a variable portion of the decreased attenuation
present on early enhanced scans; (ii) a focal area or rim of
contrast enhancement surrounding an abscess; and (iii)
uncommonly, delayed contrast staining far from the
lesions detected on early scans [32,33].
Other CT signs of infection include focal or global
enlargement of the kidney, obliteration of the renal sinus
and perinephric fat planes, thickening of Gerota's fascia,
and calyceal effacement caused by swelling of adjacent
renal parenchyma and thickening of the pelvicalyceal
wall [8±10]. Soft-tissue attenuation ®lling defects in the
collecting system may represent in¯ammatory debris,
blood clots or sloughed tissue from papillary necrosis.
Uncomplicated acute pyelonephritis in adults had been
thought not to cause signi®cant permanent anatomical
or physiological sequelae. Occasionally, severe cases of
the disease result in papillary necrosis and renal
parenchymal scarring. More recent data suggest that
new scars may eventually appear on CT in up to half of
the patients who have acute infections with or without
abscess formation [34]. In moderate and severe cases of
infection, nephrographic abnormalities may be present
for several weeks to months, well after the clinical
symptoms and laboratory ®ndings have returned to
normal [12,35]. It is important not to confuse such
residual changes with ongoing disease requiring con-
tinued therapy.
Ultrasonography, in our experience, is insensitive for
evaluating renal infection compared with enhanced CT;
US may detect acute pyelonephritis as a hypoechoic area
or occasionally a hyperechoic area. This is caused by the
Fig. 2. Acute pyelonephritis in a 58-year-
old man with impaired renal function. An
axial view of a fast spin-echo inversion-
recovery pulse sequence (TR/TE/IR: 4800/
15/160) after the IV administration of
gadolinium reveals a large (straight arrow)
and small (curved arrow) focal area of
increased signal intensity in the right
kidney. The remaining right renal
parenchyma shows heterogeneous signal
intensity. Areas of acute pyelonephritis
appear hyper-intense. Note a normal left
kidney with homogeneously low signal
intensity.
presence of interstitial oedema within the affected renal
tissue. This process also results in loss of the normal
corticomedullary junction differentiation on the ultra-
sonogram. In a recent review of 12 patients with acute
pyelonephritis assessed using power and colour Doppler
US, and enhanced helical CT, power Doppler US was
shown to be superior to colour Doppler US in de®ning the
extent of hypoperfusion caused by infection, but inferior
to helical CT [36].
Excretory urography plays a minor role in imaging the
kidneys in patients with acute renal infection, although it
is often requested to screen for urinary obstruction. If
used when CT is not readily available, nephrotomogra-
phy after IV contrast administration should be obtained.
About 75% of all affected patients have normal urograms
[19,37]. If the investigation is limited to those patients
who do not respond to appropriate antibiotic therapy
72 h after initiating treatment, there are signi®cantly
more patients with urographic ®ndings that have
immediate clinical signi®cance. Excretory urographic
®ndings in acute pyelonephritis include renal enlarge-
ment, compression of the collecting system, delayed
contrast medium excretion, and diminished contrast
medium concentration. Urography is considered neces-
sary to diagnose papillary necrosis, especially in the
setting of a diabetic patient with haematuria [21].
Fraser et al. [38] showed that CT was almost as
sensitive as cortical scintigraphy in detecting focal
abnormalities in adult patients with the clinical and
laboratory diagnosis of acute pyelonephritis. Focal areas
of decreased uptake on renal cortical scans are not
speci®c for acute pyelonephritis and may represent
abscess, infarct, cyst, or tumour.
With recent improvements in coil technology and the
introduction of fast-imaging techniques, there have been
promising results with MRI for evaluating acute renal
infection both experimentally [39] and clinically in
children [40,41] (see next section). Clinical experience
# 2000 BJU International, 86 Suppl. 1, 70±79

a glucoheptonate are the agents used most often. Cortical
b tions should at least be evaluated for possible urinary
Fig. 3. Acute pyelonephritis in an 8-month-old boy. a, A long-
itudinal view on a grey-scale ultrasonogram of the right kidney
reveals focal swelling of the upper pole (M). Note the loss of
corticomedullary differentiation. b, Decreased perfusion (M) visible
on the power Doppler ultrasonogram.
in adults is currently limited. In our experience, MRI is a
useful tool in evaluating adult patients with suspected
acute pyelonephritis in whom iodinated contrast media
are contraindicated (Fig. 2). However, the cost is a
signi®cant issue.
Acute pyelonephritis in children
Acute pyelonephritis in children is often associated with
VUR and represents the most severe type of UTI. The
in¯ammatory changes of acute pyelonephritis are
reversible and cause no renal scarring in most cases.
However, in others acute pyelonephritis results in
irreversible renal scarring [42] which can subsequently
lead to hypertension and chronic renal failure [43].
Prompt treatment with appropriate antibiotics can
minimize or even prevent parenchymal scarring [44].
Imaging plays a much greater role in the diagnosis of
pyelonephritis in children than in adults as the clinical
# 2000 BJU International, 86 Suppl. 1, 70±79
IMAGING IN ACUTE RENAL INFECTION 73
and laboratory ®ndings cannot reliably differentiate
upper from lower tract infection [45].
In childhood, imaging is indicated with the ®rst
documented UTI in all boys and in all girls <5 years
old; all older girls with febrile or recurrent UTIs should
also be evaluated [42]. Conventional or radionuclide
voiding cysto-urethrography is usually indicated to
determine the presence and degree of re¯ux once the
patient has been adequately treated with antibiotics.
Cortical scintigraphy is more sensitive than urography
or US for detecting acute pyelonephritis and renal scarring
[46±53]. Differential renal function can be assessed
quantitatively by a renal scan; 99mTc-DMSA or 99mTc-
scintigraphy will detect focal or global areas of decreased
uptake of tracer, preserving the renal contour. There may
also be swelling of the kidney corresponding to the areas of
acute in¯ammation. Renal cortical abnormalities are
present in 50±91% of febrile children with UTI but most of
these patients have no detectable VUR [45,50]. When
VUR is present, renal cortical scintigraphic ®ndings are
abnormal in 79±86% of the kidneys in patients with
evidence of VUR overall and in all patients with moderate
or severe re¯ux (grades III±V) [45,50].
Ultrasonography is not invasive and is painless; it is as
sensitive as excretory urography for detecting signi®cant
structural abnormalities of the urinary tract in children
[42]. Children requiring hospitalization for febrile infec-
obstruction with US [42]. Typical US ®ndings of acute
pyelonephritis include focal or global areas of decreased
or occasionally increased echogenicity (Fig. 3a), oblit-
eration of corticomedullary differentiation, and thicken-
ing of the wall of the renal pelvis [54]. Doppler (colour or
power) US shows areas of decreased or occasionally
increased perfusion (Fig. 3b) [54,55]. Doppler US can be
considered as a possible alternative to CT. In one study,
Doppler US showed renal parenchymal abnormalities in
17 of 22 patients with acute pyelonephritis con®rmed by
CT [55]. In a recent study using renal cortical
scintigraphy as the gold standard, Doppler US was
superior to grey-scale US for the diagnosis of acute
pyelonephritis [54]. Doppler US had a sensitivity of 20%,
a speci®city of 97%, a positive predictive value of 96%,
and a negative predictive value of 30%, while grey-scale
US had corresponding values of 46%, 87%, 89% and 41%
[54]. In the same study, the abnormal Doppler US
®ndings helped to predict future scarring with a positive
predictive value of 85.7% and a negative predictive value
of 37.2% [54]. However, negative results on grey-scale
and Doppler US do not preclude the diagnosis of acute
pyelonephritis [48,51±54].
Pennington et al. [39] showed that gadolinium-
enhanced fast spin-echo inversion-recovery MRI was
74 A. KAWASHIMA et al.
85±92% sensitive and 94±95% speci®c in detecting
experimentally induced acute pyelonephritis in piglets.
More recently, cortical scintigraphy, spiral CT and MRI
were equally sensitive and reliable for detecting acute
pyelonephritis, but power Doppler US was signi®cantly
less accurate [56]. In 37 paediatric patients with
suspected acute pyelonephritis, gadolinium-enhanced
MRI was superior to renal scintigraphy; MRI detected
more lesions in 78% and had better interobserver
agreement than renal cortical scintigraphy, which
detected abnormalities in 68% [40]. MRI has better
spatial resolution than cortical scintigraphy. In another
clinical study, MRI detected lesions of acute pyelo-
nephritis in two of four patients and areas of scarring
in all four [41]. In children, when a complication of
pyelonephritis is suspected, CT remains the imaging
study of choice, despite the radiation exposure.
Septic emboli
One cause of acute renal infection in adults is
haematogenous seeding (septic emboli) of the kidney as
the result of IV drug abuse, subacute bacterial endocar-
ditis, or a distant primary focus (e.g. tooth abscess,
respiratory tract infection) [5,35]. More than 90% of
septic emboli are caused by Staphylococcus aureus and
Streptococcus spp. Haematogenous infection begins in the
renal cortex and usually appears as multiple, peripherally
located lesions. Typical CT ®ndings are small wedge-
shaped or rounded areas of hypo-attenuation in the renal
cortex. When septic foci of infection coalesce and spread
into the renal parenchyma, it may not be possible to
distinguish ascending and haematogenous infection
[2,12]. Cortical abscesses may be found and associated
with perirenal extension of the abscess [5]. The CT
features of typical cortical abscesses include a rim of
contrast enhancement at the periphery of the hypodense
lesion. Ancillary CT ®ndings in the lung, spleen, muscle,
and skeleton are also indicative of septic emboli.
Renal, perirenal (perinephric) and pararenal
abscess
Severe in¯ammation may cause multiple small suppura-
tive foci which coalesce into a larger focal collection of
pus (with or without a discrete surrounding reparative
type of `wall'). This latter complication is by de®nition an
acute renal abscess. Perinephric abscess (abscess within
the perirenal `Gerota's' fascia) may result from rupture of
a renal abscess into the perirenal space, but most often
develops directly from acute pyelonephritis. Diabetic
patients with calculi and patients with septic emboli
are at greater risk of developing abscess. Diabetes mellitus
is found in 75% of patients with perinephric abscess.
Urine culture in patients with renal abscess can be
negative in 15±20% [15]. Perinephric abscess can extend
through Gerota's fascia to the pararenal space (pararenal
abscess outside Gerota's fascia). Abscesses may involve
the psoas muscle and may extend to the pelvis and groin.
Extrarenal infection in the chest and abdomen (e.g.
diverticulitis, pancreatitis) may also extend into the
perinephric space. Perinephric and pararenal abscess
may develop as a complication of xanthogranulomatous
pyelonephritis.
Excretory urography may occasionally show a renal
mass with reduced excretion associated with poorly
opaci®ed or effaced adjacent calyces, or may show a
localized cortical bulge when the abscess is large and in
the cortex [37]. Depending on the location of the abscess
within the kidney, the pelvicalyceal system may be
compressed, displaced, or normal. Perinephric abscesses
may obscure or enlarge the renal contour and may
displace the kidney.
On US, a typical renal abscess appears as a hypo-echoic
or anechoic complex mass with increased transmission of
sound (Fig. 4a). The borders become increasingly well
de®ned as the abscess encapsulates. Internal echoes that
move with changing position of the patient represent
debris within the abscess cavity. Unfortunately, some
abscesses that are obvious on CT fail to show the expected
characteristics on US of a ¯uid-containing mass [35]. For
example, an abscess may appear as a hypoechoic, poorly
margined mass with scattered low-amplitude echoes and
poor transmission of sound [14], appearances which also
occur in focal acute pyelonephritis with no abscess. Serial
ultrasonograms can be used to follow this type of lesion,
but CT will usually provide much more useful informa-
tion. In a series of patients assessed by Soulen et al. [14],
US failed to detect seven of 15 intrarenal and extrarenal
abscesses revealed by CT.
CT is currently the most accurate modality for
detecting and following renal abscesses [6,14,22]. An
abscess usually appears as a well-de®ned low-density
mass (Fig. 4b). An irregular and thick wall or pseudo-
capsule is better imaged after contrast enhancement
[6,34]; the lique®ed purulent material does not enhance.
Gas (CT numbers of fx150 HU) density in a cystic
mass that is ¯uid-®lled (CT numbers of t 10 HU)
strongly suggests abscess formation [57]. Renal par-
enchyma around the abscess that appears hypodense on
early scans may appear hyperdense on delayed views.
Perinephric abscesses appear as soft tissue and/or of ¯uid
density within the perirenal space (Fig. 4b). Abscesses
may involve the psoas muscle and extend to the iliac
fossa and groin. Pararenal abscesses appear similar
except for location and may or may not be associated
with perinephric or renal abscesses. Gas may occasion-
ally be present.
# 2000 BJU International, 86 Suppl. 1, 70±79

a b
Fig. 4. Renal abscess with extensive retroperitoneal and pelvic extension in a 42-year-old man. a, Longitudinal ultrasonogram of the right
kidney shows a 3r4 cm complex cystic mass with irregular wall and septum (arrows). Note the hypoechoic layer posterior to the right kidney
(arrowheads). b, Enhanced helical CT scan shows a thick-walled cystic mass (arrow) in the right kidney, which is displaced by large right
perinephric and pararenal ¯uid collections involving the right psoas muscle (P). (reprinted with permission from [8]).
Occasionally, a renal abscess may mimic a necrotic
carcinoma as both lesions may have a ¯uid centre and a
thickened or irregular wall which enhances after contrast
medium. The patient's symptoms usually clarify the
diagnosis injection. However, in some patients percuta-
neous aspiration and drainage may be indicated, and
cytological examination of the ¯uid may be needed.
Rarely, a post-in¯ammatory cystic ¯uid collection may
develop in the area of acute pyelonephritis during or after
the course of antibiotic treatment. These collections are
usually small (<3 cm in diameter) with no appreciable
wall thickening or contrast enhancement. However, CT-
guided needle aspiration may be required to exclude an
abscess, if the ¯uid collection does not resolve.
Emphysematous pyelonephritis
Emphysematous pyelonephritis is a fulminant gas-form-
ing infection of the renal parenchyma [58±60]. Diabetes
mellitus is present in 85±100% of the patients and is
often uncontrolled. Most patients present with symptoms
of severe acute pyelonephritis, urosepsis, or shock, and
calculi may be present. Escherichia coli, Klebsiella
pneumonia and Proteus mirabilis are the most common
organisms. Emphysematous pyelonephritis in the trans-
planted kidney has been reported [61,62]. Gas in
emphysematous UTI has been attributed to mixed acid
fermentation of tissue glucose by gas-forming organisms
[59]. Gas can be limited to the renal collecting system,
the ureter, and the bladder. These entities are distinct
from true emphysematous pyelonephritis and have a
better prognosis [63].
Excretory urography may show mottled or crescent-
shaped gas collections in the renal parenchyma and
# 2000 BJU International, 86 Suppl. 1, 70±79
IMAGING IN ACUTE RENAL INFECTION 75
perirenal tissues in up to half of patients, and no function
in the affected kidneys in 45% [60]. The gas collections
can often go unrecognized without nephrotomography.
CT is the best modality for detecting the presence of gas
and for de®ning the extent of the disease [57,58,60,64±
66]. CT also detects gas within the renal parenchyma or
in the subcapsular, perinephric and/or pararenal space,
in the collecting system, or occasionally in the vascular
system (Fig. 5).
The typical US appearance of gas-producing renal
infections is of markedly echogenic areas within the renal
parenchyma or perirenal tissues, with distal shadowing
containing low-level echoes and reverberations [57].
Differentiation from renal calculi may be dif®cult. The
affected kidney may be completely obscured by the gas
and a plain ®lm should be obtained to differentiate air
from calculi.
MRI is of limited use for detecting gas in the urinary
tract. Gas appears as an area of signal void which cannot
be differentiated from calculi, renal calci®cation and
¯owing blood on T1- and T2-weighted spin-echo images
[57]. Concentrated gadolinium contrast agents excreted
into the collecting system also appear as signal void
because of the T2 shortening effect.
Renal scintigraphy has been used to assess renal
function and especially to evaluate the uninvolved
kidney before surgery, but otherwise it is of little value
in emphysematous pyelonephritis.
In recent studies by Wan et al. [66,67], acute gas-
forming bacterial infection of the kidneys was classi®ed
into two types based on CT and plain-®lm features.
Classic emphysematous pyelonephritis (type I), charac-
terized by parenchymal destruction, the presence of
streaky or mottled gas, and little or no ¯uid (Fig. 4), had a
76 A. KAWASHIMA et al.
worse prognosis than renal infection characterized by
either renal or perirenal ¯uid collections with bubbly or
loculated gas in the parenchyma or in the collecting
system (type II). The authors speculate that the latter
more favourable group is still capable of an immune
response.
Pyonephrosis
Infected hydronephrosis (pyonephrosis) is usually con-
sidered to be a urological emergency requiring urgent
drainage. Urinary decompression and drainage may be
accomplished by either retrograde stent placement or by
percutaneous aspiration and nephrostomy. Pyonephrosis
results from acute or more frequently chronic obstruction
and superimposed UTI [11,68,69]. Associated parench-
ymal involvement ranges from uncomplicated pyelone-
phritis to extensive destruction.
If suf®cient renal function is present, excretory
urography shows urinary tract obstruction with absent
or delayed opaci®cation of the collecting system, renal
enlargement, and occasionally a hyperdense nephro-
gram on delayed ®lms [69].
Ultrasonography may be indicated to seek evidence of
urinary obstruction in patients with acute renal infection
who do not improve with antibiotics. However, in acute
obstruction, caliectasis may be minimal, which renders
US less reliable if the diagnosis of obstruction is based on
pelvicalyceal dilatation alone. Adding resistive index (RI)
measurements with pulsed Doppler US may enhance the
sensitivity of the test in diagnosing obstruction, but there
have been no studies to examine its speci®city in patients
with infection [2]. The value of the RI is extremely
controversial. US may show echogenic material in the
dilated pelvicalyceal system, sometimes with a urine-
debris level, but often the features are those of simple
hydronephrosis [70±73].
CT is helpful in identifying hydronephrosis and deter-
mining the level and cause of obstruction [35,74]. In most
Fig. 5. Emphysematous pyelonephritis in
a 62-year-old woman with poorly
controlled diabetes mellitus. The
unenhanced CT scan shows the enlarged
left kidney with gas in the renal
parenchyma, renal pelvis (curved arrow)
and perirenal space (open arrow). Note the
gas in the left renal vein and inferior vena
cava (large straight arrows) and
thickening of Gerota's fascia on the left
(arrowheads). Calculi are present in the
collecting system bilaterally (small straight
arrows).
cases, pyonephrosis is indistinguishable from an unin-
fected hydronephrosis. The nephrogram of uncomplicated
acute obstruction may have ®ne striations, or a prolonged
corticomedullary differentiation phase, and subsequently
a prolonged homogeneous nephrogram. Conversely, acute
pyelonephritis may show a coarsely striated nephrogram.
The presence of an abnormal nephrogram (especially if
there is focal bulging of the renal contour) in the
parenchyma of an obstructed kidney suggests super-
imposed infection rather than uncomplicated hydro-
nephrosis. Unfortunately, renal parenchymal changes
are not often present. CT can also detect thickened walls of
the pelvis and ureter, ¯uid-¯uid levels (pus-urine, urine-
debris, or contrast-debris levels), and gas within the
collecting system. Clinical ®ndings are important in
differentiating hydronephrosis from pyonephrosis.
Suppurative renal infection in patients with chronic
urinary obstruction occasionally results in spontaneous
reno-colic ®stula formation [75].
Infected cyst
Occasionally a renal cyst may be secondarily infected by
haematogenous dissemination, re¯ux, surgical manip-
ulation, or cyst puncture. The clinical diagnosis of
superimposed infection of a renal cyst is dif®cult because
typically speci®c symptoms and pyuria are absent. It is
dif®cult to differentiate an infected simple renal cyst from
an abscess both clinically and radiologically [35,76,77].
An infected cyst may also mimic a renal cyst complicated
by intracystic haemorrhage on imaging studies.
Percutaneous cyst aspiration and drainage under CT or
US guidance may be indicated for diagnosis and
treatment.
Acute fungal infection
Patients with acute leukaemia and neutropenia are
susceptible to haematogenously disseminated fungal
# 2000 BJU International, 86 Suppl. 1, 70±79

infections that may seed the kidneys with multiple small
abscesses [78,79]. The most common fungal infection is
Candida. CT typically shows multiple small hypodense
lesions in the spleen, liver and kidneys. Enhanced CT is
superior to unenhanced CT in showing the lesions, but
CT is not as sensitive as a renal biopsy of the kidney in
diagnosing disseminated fungal disease [80].
Fungal renal involvement in patients with AIDS is
relatively uncommon [81]. Renal mucormycosis has
been reported in such patients in Italy. A special
propensity for vascular invasion can cause extensive
cortical infarcts and medullary necrosis in the kidneys
[82]. CT shows a mixed hypo- and hyperdense pattern in
the entire kidney.
Conclusion
While renal imaging is not routinely indicated in cases of
uncomplicated renal infection, CT is a readily available,
highly sensitive modality for the diagnosis and manage-
ment of patients with acute renal infection. Excretory
urography and US are frequently used to screen for
urinary obstruction, renal calculi, and underlying
anomalies. CT is of value in establishing the diagnosis
in equivocal cases, in evaluating high-risk patients, and
in determining the nature and extent of disease. Lesions
of acute pyelonephritis can be best shown on CT scans
obtained during the homogeneous nephrographic phase
of contrast enhancement. However, views obtained
during the excretory phase when there is pelvicalyceal
®lling with contrast medium are less equivocal for
diagnosing renal abscesses.
Cortical scintigraphy is usually the preferred imaging
study for the evaluation of children with acute pyelo-
nephritis, although power Doppler US can be considered
as a possible alternative. Recent studies have shown that
gadolinium-enhanced MRI is equal to or better than
scintigraphy in showing pyelonephritis.
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Authors
A. Kawashima, MD, Associate Professor.
C.M. Sandler, MD, Professor and Vice Chairman.
S.M. Goldman, MD, Professor and Chairman.
Correspondence: A. Kawashima, MD, Department of Radiology,
The University of Texas-Houston Medical School, Lyndon B.
Johnson General Hospital, 5656 Kelley Street, Houston, Texas
77026, USA.
e-mail: akira.kawashima@uth.tmc.edu