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Granulomatous Pyelitis Associated with Urinary Obstruction: a Comprehensive Clinicopathologic Study

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Granulomatous Pyelitis Associated with Urinary Obstruction: a Comprehensive Clinicopathologic Study Modern Pathology (2006) 19, 1130–1138 & 2006 USCAP, Inc All rights reserved 0893-3952/06 $30.00 www.modernpathology.org Granulomatous pyelitis associated with urinary obstruction: a comprehensive clinicopathologic study Gulfiliz Gonlusen1,2, Anh Truong3, Steven S Shen1,4, Horacio E Adrogue3, Venkat Ramanathan3 and Luan D Truong1,2,3,4 1Department of Pathology, The Methodist Hospital, Houston, TX, USA; 2Department of Pathology, Baylor College of Medicine, Houston, TX, USA; 3Department of Medicine, Renal Section, Baylor College of Medicine, Houston, TX, USA and 4Department of Pathology, Weill Medical College of Cornell University, New York, NY, USA Urinary obstruction is rarely associated with a distinct granulomatous inflammation, which involves the pyelocalyceal system and closely simulates infectious conditions including tuberculosis. Its clinicopathologic features, however, have not been adequately studied since there are only seven isolated reported cases. In a comprehensive study of 112 kidney specimens with urinary obstruction, we identified five cases of granulomatous pyelitis. The features of these cases were detailed and compared with the previously reported cases. Among the five identified subjects, three patients had history of urolithiasis and two had ureteral stenosis and all had stent placement 7 weeks to 12 years before nephrectomy for relief of the unilateral urinary obstruction. The age distribution was between 38 and 81 years. Two had end-stage renal disease or chronic renal failure. The pyelocaliceal system showed frank hydronephrosis (1 case) or partial dilatation (4 cases) and contained cheesy and gritty material in its lumen. Each case showed severe granulomatous inflammation, which was limited to the pelvic wall and closely associated with calcified debris, necrotic inflammatory cells, and material consistent with Tamm–Horsfall protein. The kidney showed chronic tubulointerstitial nephritis but without granulomas. Cultures of urine, blood, and the renal pelvic content, and special stains of tissue sections did not show fungi or mycobacteria in any case. Many of these features were also observed in previously reported cases. Granulomatous pyelitis is a rare but distinct cliniocopathologic entity characterized by severe noninfectious granulomatous inflammation limited to the renal pelvis, which is uniformely asociated with urinary obstruction and pyelocalyceal dilatation and may develop in response to accumulated calcified material in the renal pelvis. Awareness of this entity and its characteristic clinicopathologic features also helps eliminate an infectious etiology with obvious treatment and prognostic implications. Modern Pathology (2006) 19, 1130–1138. doi:10.1038/modpathol.3800638; published online 19 May 2006 Keywords: urinary obstruction; granulomatous inflammation of kidney; granulomatous pyelitis; lithiasis; mycobacteria; fungus Chronic urinary obstruction causes characteristic end result is variable loss of renal parenchyma. changes of the pyelocalyceal system and the kidney. These changes are often so characteristic that a The pyelocalyceal system shows dilatation, intact diagnosis of obstructive uropathy can be readily urothelium with reactive atypia, active inflamma- made in a nephrectomy specimen without knowl- tion of its wall, and thickening of its muscularis. edge of the clinical condition of urinary obstruc- The kidney changes include tubular atrophy, inter- tion.1 stitial fibrosis, and active interstitial inflammation, Urinary obstruction, however, rarely does not but the glomeruli and blood vessels are intact. The induce the characteristic changes described above, but is associated with a distinct granulomatous inflammation, which involves the pyelocalyceal Correspondence: Dr LD Truong, MD, Department of Pathology, system and closely simulates infectious conditions, MS 205, The Methodist Hospital, 6565 Fannin Street, Houston, for which the term pseudotuberculous chronic TX 77030, USA. pyelonephritis was coined.2 In spite of the obvious E-mail: [email protected] Received 22 February 2006; revised and accepted 24 April 2006; diagnostic and therapeutic implications of this published online 19 May 2006 condition, its clinicopathologic features have not Granulomatous pyelitis G Gonlusen et al 1131 been adequately studied since only seven isolated performed. The patient was alive and well without cases were previously reported.2–7 features of tuberculosis at most recent follow-up. We wish to describe five new cases and compare them with previously reported cases to comprehen- Case 2 sively assess the morphologic spectrum, pathogen- A 38-year-old man presented with severe right flank esis, and diagnostic implications of this entity. pain. His past medical history was significant for end-stage renal disease of unknown etiology, requir- ing maintenance hemodialysis for the past 6 years, Materials and methods partial right nephrectomy at the age of 28 years for hydronephrosis due to lithiasis, and placement of Cases of nephrectomy with chronic urinary obstruc- right ureteral stent at the age of 30 years for tion of any cause including urinary tract neoplasms persistent urinary obstruction. During the current during an 11-year-period from 1994 to 2005 were admission, the laboratory studies showed WBC reviewed to identify those with granulomatous 16.3 Â 103 cells/c.mm, Hgb 7.1 g/dl, Hct 22.3%, pyelitis. Among the 112 such cases, five cases of platelet 705 Â 103 cells/c.mm, sodium 143 mEq/l, GP were identified. Selected tissue sections of each potassium 4.8 mEq/l, chloride 108 mEq/L, serum case of GP were subjected to histochemical stains creatinine 7.1 mg/dl, glucose 128 mg/dl, calcium including Masson’s trichome, periodic acid-Schiff, 9.7 mg/dl, and a serum parathyroid hormone 91 pg/ von Kossa, alizarin red, Gram stain, acid fast bacilli dl (normal 13–65). There was cutaneous induration stain, and Gomori’s methenamine silver (GMS) stain in the right arm and right gluteal area, the biopsies of for fungi; and to immunostain for Tamm–Horsfall which showed calcinosis cutis. A plain abdominal protein (Rabbit polyclonal antibody, Biomedia (Rar- X-ray showed an intact urinary stent in the right itan, CA), dilution 1:200). The clinical features and ureter and multifocal calcification in the right follow-up information, with special attention to kidney, consistent with lithiasis. Urine and blood those that may explained the granulomatous inflam- cultures were negative for bacteria and fungi. He mation, were obtained from the medical records. was initially treated with replacement of the ureteral stent, but due to progressive pain right nephrectomy Results was performed the next day. Clinical Features Case 3 An 81-year-old woman presented with progressive The clinical features are reported below and sum- right flank pain, chills, fever, and sweating. She has marized in Table 1. required hemodialysis for the past 3 months for diabetic end-stage renal disease. Twelve years ago, Case 1 she underwent radical cystectomy with ileal con- A 51-year-old woman presented with right flank duit for bladder cancer, which was later complicated pain. Renal imaging study showed right hydrone- by recurrent right ureteral obstruction requiring phrosis and right ureteral stenosis 4 cm from the multiple stent placements. Physical examination bladder. The left kidney, left pyelocalyceal system, showed a temperature of 102.6 1F, blood pressure left ureter, and urinary bladder were normal. Her 130/70 mmHg, pulse rate 84/min and respiratory past medical history was significant for ‘tuberculo- rate of 14/min. There was a right nephrostomy tube sis of the right elbow’ when she was 9 years old and in place. Laboratory studies showed WBC 9.8 Â 103 repeated urinary tract infection. She was treated cells/c.mm, Hgb 11.7 g/dl, Hct 37.2%, platelets with right urinary stent twice and antibiotics for 255 Â 103 cells/c.mm, serum sodium 135 mEq/l, po- tuberculosis including INH and rifampin for 18 tassium 3.5 mEq/l, chloride 95 mEq/l, glucose months before this admission. Renal imaging at this 130 mg/dl, calcium 7.7 mg/dl, phosphorus 3.1 mg/ time showed an intact stent in the right renal pelvis, dl, creatinine 5.7 mg/dl, total serum protein 6.8 g/dl, and a cystic area in the lower pole of the right serum albumin 3.2 g/dl, and serum uric acid 5.5 mg/ kidney associated with calcification, but there was dl. Urine analysis showed 2 þ protein, many WBC’s no hydronephrosis. The left urinary tract remained and Gram-positive cocci in urine culture, but no normal. Currently, there were no clinical, bacterio- fungi or mycobacteria. Blood cultures were negative. logic or imaging features of active tuberculosis The patient underwent a right nephrectomy. Laboratory studies during this admission showed WBC 8.6 Â 103 cells/c.mm, Hgb 12.2 g/dl, Hct 34.6%, Case 4 platelet 256 Â 103 cells/c.mm, serum sodium A 50-year-old man with a past medical history of 140 mEq/l, potassium 3.9 mEq/l, chloride 105 mEq/ renal lithiasis 8 years ago presented with periodic l, glucose 87 mg/dl, calcium 8.9 mg/dl, total serum abdominal pain in the past several months. Labora- protein 7.5 g/dl, serum albumin 4.7 g/dl, BUN tory studies showed Hgb 10.3 g/dl with normal WBC 11 mg/dl, and serum creatinine 0.9 mg/dl. Repeated and platelet counts (WBC 10.4 Â 103 cells/c.mm urine cultures were negative for fungi and bacteria, platelets 284 Â 103cells/c.mm), sodium 144 mEq/l, including mycobacteria. Right nephrectomy was potassium 4.4 mEq/l, chloride 105 mEq/l, creatinine Modern
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