ORIGINAL REPORTS

Klinik und Poliklinik fuer Urologie WestfaelischeWilhelms-Universitaet Muenster
Albert-Schweitzer-Str. 33, 48149
Muenster, Germany

Patient History

• 54 year-old female
• Recurrent cystitis and pyelonephritis since 13 years, nephrolithiasisin both kidneys for more than 10 years, currently no urinary frequency,no dysuria
• Since 2 years: recurrent bronchopneumonias of unknown origin
• Chronic fatigue, persistent coughing

The patient has no other urologic disease. Recurrent bronchopneumoniasduring the last 24 months

Medications

Pipemidic acid 200 mg twice daily since 5 years

Physical Examination

Obesity, no tenderness of the flank or the abdomen, nofever, no other abnormalities

Presenting Labs and Imaging Studies

1. Blood/Serum

ESR (1 minute): 90 mm; RBC, WBC, serum-CRP, -creatinine,-BUN, -electrolytes, -ALT, -AST, -g-GT, -Bilirubin and -LDH within normalranges
2. Urine Sediment

no hematuria, no leukocyturia, no other abnomalities
3. Urine Culture

negative
4. Urine Testing for TB

first MSU of the morning (3 times): no acid-fast rod-shapedbacilli on microscopy, TB Test negative, TB culture negative 3 times
5. Chest-radiographs

solitary round opacity of 3 cm in diameter in the caudallobe of the left lung
6. Intravenous Urogram (IVU)(Fig.1)

Left kidney: extensive nephrolithiasis especially ofthe upper pole.
Right kidney: duplicated unit, 3 calculi smaller than5 mm.
7. Retrograde Pyelography of the Left Kidney

The upper calyces of the left kidney are dilated(Fig.2)
8. CT-scan
• partly calcified tumor of 3 cm in size in the left dorsalcosto-phrenic angle, left hemidiaphragm thickened(Fig.3)
• left kidney: enlarged, calices of the upper pole and renalpelvis enlarged, nephrolithiasis in the upper pole; normal parenchyma inthe lower pole (Fig. 4)
• no visible connection between the lesion in the kidney andin the lung
9. Radioisotopic Imaging (Tc 99m - MAG-3)

normal total renal clearance; right renal unit with 70%of total renal function; left renal unit with 30% of total renal function
10. Bronchoscopy (including bronchio-alveolar lavage, trans-bronchialbiopsy and cytology with the covered brush)
• no visible tumor, no tuberculous cavity
• Cytology and biopsy: chronic alveolitis, no neoplastic tissueor specific inflammation
• Bacteriology: Proteus mirabilis

The patient underwent radical left nephrectomy with simultaneousatypical resection of the diseased segment in the caudal lobe of the leftlung. The surgical approach was performed through a left thoracoabdominalincision. During the operation extensive perinephric scarring was found.A scarred fistulous tract was identified, which connected the dorsal aspectof the upper pole of the left kidney with the diseased lung segment. Oninspection of the specimen after nephrectomy, the renal pelvis and caliceswere filled with pus and renal stones. Histopathological analysis showedthe presence of xanthogranulomatous pyelonephritis (XPGN) of the left kidneywhich caused the formation of a nephrobronchial fistulous tract. The nephrobronchialfistula was the cause of the recurrent bronchopneumonias. Postoperativelythe patient fully recovered and is free of recurrence of pneumonia for24 months.

Nephro-bronchial fistula is a rare condition. The pulmonarysymptoms can be much more impressive than the underlying urological disease.Generally, paranephritic abscess is considered to be the most common etiologyof a nephro-bronchial fistula¹. Nephro-bronchial fistula causedby xanthogranulomatous pyelonephritis (XPGN) is even less common; a medlinesearch resulted in 9 cases reported since 1966.

XPGN is an aggressive subtype of common chronic pyelonephritis.It is usually found unilaterally and is three times as common in femalesthan in males. Generally, the diseased kidney is enlarged and deformedby extensive scarring. Renal stones, infection with E. coli and Proteusmirabilis, and urinary obstruction are common. The inflammation often extendsinto the perinephric space and can be confused with neoplastic infiltrationon CT scans or macroscopically. The etiology of the disease remains unclear.Until today, it can be difficult to differentiate XPGN from other renalmasses preoperatively. Usually, the final diagnosis is made by the pathologistafter nephrectomy. Fistulas caused by XPGN are uncommon, but it has beenreported in lung, the spleen, the colon, the duodenum and the skin².There have been reported cases of urothelial cell carcinomas and XPGN inthe same kidney³.

In the case presented, surgical resection was the appropriatetreatment. We chose radical nephrectomy because the contralateral renalunit had 70% of the total renal function. The diagnosis was unclear preoperatively.Partial nephrectomies in XPGN have been successfully performed, and inretrospect, an upper pole resection of the left kidney might also havebeen appropriate in the case presented here.

References

1. Rubin, S. A. and Morettin, L. B.: Nephrobronchial Fistula: an uncommonmanifestation of inflammatory renal disease, J. Urol. 127, 103-105, 1982.
2. Chuang, C.K., Lai, M. K., Chang, P. L., Huang, M. H.,Chu, S. H., Wu, C.J. and Wu, H. R.: Xanthogranulomatous pyelonephritis: experience in 36cases. J. Urol. 147 (2), 333-336, 1992.
3. Siemer, S. W., Humke, U., Kramann, B., Becht, E.and Ziegler, M.: Die XanthogranulomatösePyelonephritis: Eine Übersicht mit Kasuistiken zur Differentialdiagnoseund verlaufsorientierten Therapie, Akt. Urol. 25,200- 207, 1994.