|Year : 2015 | Volume
| Issue : 1 | Page : 85-86
Xanthogranulomatous pyelonephritis: An uncommon entity with review of literature
Monika Rathi1, Satish Kumar Budania2, Ankur Mittal3, Mohammad Khalid4, Nidhi Verma5
1 Department of Pathology, Lala Lajpat Rai Memorial Medical College, Meerut; Department of Pathology, Teerthanker Mahaveer Medical College and Research Center, Moradabad, Uttar Pradesh, India
2 Department of Psychiatry, Subharti Medical College, Meerut, Uttar Pradesh, India
3 Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4 Department of General Surgery, Mayo Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
5 Department of Pathology, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India
|Date of Web Publication||14-Jan-2015|
Dr. Monika Rathi
228/16, Saket Colony, North Civil Lines, Muzaffarnagar - 251 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Xanthogranulomatous pyelonephritis (XGP) is an uncommon entity affecting predominantly females between the ages 45-55 years. The disease is usually associated with urinary tract infection and the patient presents with flank pain, dysuria and fever. It has to be differentiated from various benign and malignant conditions including tuberculosis (TB) and renal cell carcinoma. Surgery is the definitive treatment of choice. Hereby, a case of 45-year-old, hypertensive female, who presented with uncommon condition is being reported.
Keywords: Nephrectomy, pyelonephritis, rare, xanthogranulomatous
|How to cite this article:|
Rathi M, Budania SK, Mittal A, Khalid M, Verma N. Xanthogranulomatous pyelonephritis: An uncommon entity with review of literature. CHRISMED J Health Res 2015;2:85-6
|How to cite this URL:|
Rathi M, Budania SK, Mittal A, Khalid M, Verma N. Xanthogranulomatous pyelonephritis: An uncommon entity with review of literature. CHRISMED J Health Res [serial online] 2015 [cited 2020 Nov 23];2:85-6. Available from: https://www.cjhr.org/text.asp?2015/2/1/85/149358
| Introduction|| |
Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic destructive granulomatous process of renal parenchyma.  The age of occurrence of the disease varies from 20-60 years (mean age = 45yrs).  Women are affected more commonly than men.  The disease is unilateral in majority of the cases. However, cases with bilateral XGP are also reported.  This case is being reported because of its uncommon occurrence.
| Case Report|| |
A 45-year-old female presented to the hospital with abdominal pain. Vital signs (except blood pressure) were within normal limits. Patient was hypertensive for 8 months. All hematological investigations except except Erythrocyte Sedimentation Rate (ESR) were normal. ESR was found to be raised (30 mm/hour). Urine analysis revealed that all parameters were within normal limits. Urine culture was done and urine was found to be sterile. Ultrasonographic examination (USG) showed ureteric stone with hydronephrosis and parenchymal thinning. DTPA scan showed non-functioning left kidney . Elective left sided nephrectomy was done and the nephrectomy specimen was sent to histopathology lab. The patient gave consent for the reproduction of her clinical history or reports for research purposes. Gross examination showed normal sized kidney with scars on its outer surface. Cortico-medullary junction could not be appreciated [[Figure 1]a]. Microscopic examination showed destruction of normal renal elements in the involved area with dilated tubules showing thyroidisation. Sheets of foamy macrophages with admixed lymphocytes suggestive of xanthogranulomatous reaction was seen [[Figure 1]b-d].
|Figure 1: (a) Gross image of xanthogranulomatous pyelonephritis showing renal atrophy and loss of cortico-medullary junction, (b) Renal tubules showing thyroidisation (H and E, ×400), (c) Xanthogranulomatous pyelonephritis showing sheets of foamy macrophages (H and E, ×400), (d) Xanthogranulomatous pyelonephritis showing giant cells (H and E, ×400)|
Click here to view
| Discussion|| |
The most frequent presenting symptoms are flank pain, dysuria and fever. Physical examination may show palpable, tender flank mass. It is frequently associated with urinary tract infection or nephrolithiasis. 
Urine cultures most often reveal E. coli or P. Mirabilis.  Computed tomography (CT) is the mainstay of diagnostic imaging and shows low density fluid filled areas in renal parenchyma and findings indicating perinephric extension.  There are two forms of XGP on CT findings: Diffuse (85%) and focal, localised or segmental form (15%). The diffuse form is usually confused with an abscess whereas focal form is most commonly confused with a tumour. 
Grossly, kidney is enlarged and may show hydronephrosis and calculi.  However, histologically it shows large sheets of foamy histiocytes, giant cells and other inflammatory cells. , Immunohistochemistry (IHC) in cases of XGP shows diffuse positivity for CD 68, vimentin and negativity for epithelial markers, desmin, smooth muscle actin. Thus IHC can be used to differentiate XGP from renal carcinoma in cases of doubt. Renal cell carcinoma (RCC) shows positivity for CD 10 and epithelial markers whereas vimentin positivity is seen in both XGP and RCC. 
It is classified in three stages according to the involvement of the adjacent tissue. Stage 1: Disease is confined to the renal parenchyma only; Stage 2: Disease process involves renal parenchyma along with perinephric fat; Stage 3: Nephric and perinephric disease has now extended to the adjacent structures and retroperitoneum. In Stage 3 formation of psoas abscess along with nephrocolonic and nephrocutaneous fistulas are also seen. 
The first line of treatment for focal disease is antibiotic treatment with symptomatic management. However, diffuse or advanced disease does not resolve with antibiotics alone and requires nephrectomy. 
| Acknowledgement|| |
We acknowledge Engineer Ayush for his technical help. We also acknowledge Dr. Seema Awasthi and Teerthanker Mahaveer Medical College and Research Center for their support.
| References|| |
Li L, Parwani AV. Xanthogranulomatous pyelonephritis. Arch Pathol Lab Med 2011;135:671-4.
Fallatah A, Tarakji M, Amuesi J. Xanthogranulomatous pyelonephritis: A retrospective study of 10 cases and review of literature. Saudi J Kidney Dis Transpl 2001;12:520-4.
Zorzos I, Moutzouris V, Korakianitis G, Katsou G. Analysis of 39 cases of xanthogranulomatous pyelonephritis with emphasis on CT findings. Scand J Urol Nephrol 2003;37:342-7.
Leoni FA, Kinleiner P, Revol M, Zaya A, Odicio A. Xanthogranulomatous pyelonephritis: Review of 10 cases. Arch Esp Urol 2009;62:259-71.
Malek RS, Elder JS. Xanthogranulomatous pyelonephritis: A critical analysis of 26 cases and of the literature. J Urol 1978;119:589-93.