APOSTEMATOUS NEPHRITE

From Big Medical Encyclopedia

APOSTEMATOUS NEPHRITE (late lat. apostematosus, from grech, apostema an abscess, abscess; synonym pustulous nephrite) — the metastatic suppurative process in a kidney which is shown formation of a set of pustules it is preferential in its cortical substance. And. N — one of forms of acute pyelonephritis; occurs at 36% of patients with acute pyelonephritis. Among patients with diseases of the kidneys which are treated in urological hospitals, And. the N is observed in 4,5% of cases.

The etiology

the Infection gets into a kidney in the hematogenous, limfogematogenny way. If it is brought from the center of a purulent infection located far from a kidney and uric ways, then activators of an inflammation usually are gram-positive cocci, in the main staphylococcus. At primary localization of an infection in uric ways to a kidney get colibacillus, proteas, a pyocyanic stick more often, etc. It is more often observed secondary And. N.

At obturation of uric ways And. the N preferential is unilateral; at a septicopyemia (see. Sepsis ) often both kidneys are surprised.

Pathological anatomy

In 24% of cases And. the N is combined with an anthrax of a kidney. This two types of purulent damage of a kidney represent pathogenetic the uniform process which is coming to light only in the different sequence and intensity of the development. For And. N existence of multiple small abscesses is characteristic, is preferential in cortical substance; for an anthrax of a kidney — existence of the localized suppurative process differing in the tumorous progressing growth of inflammatory infiltration without bent to further abscessings).

Fig. 1. Multiple rashes of pustules on a back surface of a kidney. Reactive thickening and infiltration of a pararenal fatty tissue. Fig. 2. The same kidney on a section: pustules are located preferential in a bast layer.

At And. the kidney is increased by N, serovishnevy color. Pararenal cellulose is edematous. After removal from a kidney of the fibrous capsule the abscesses located odinochno or groups are visible multiple small, the sizes from a pin head to a pea. On a section of a kidney find small abscesses in marrow (tsvetn. fig. 1 and 2). Microscopically — the multiple centers of a purulent inflammation in intersticial fabric. In a circle of malpigiyevy balls — accumulations of small-celled infiltrates with the centers of a necrosis. Uric tubules are squeezed by perivascular infiltrates.

Pathogeny

to Development And. the N favors a number of factors: the previous diseases of uric bodies, weakening of protective forces of an organism, disorders of urodynamic affecting in disturbance of a passage of urine, existence of the dysplastic centers in renal fabric, inborn immaturity of nephrons. Disturbance of passability of uric ways is most often caused by existence in them of a concrement, narrowing of their gleam, adenoma of a prostate.

An infection, having got into a kidney, in the beginning it is localized in intersticial fabric. At a so-called urinogenny way of developing of an infection microorganisms from urinogenital bodies get on venous or limf, to a bed into blood, and then are brought in an interstitium of a kidney. In addition, the infection can get from pyelocaliceal system into intersticial fabric at piyelorenalny refluxes.

Microbes settle in venous peritubulyarny capillaries, and then get into an interstitium where cause formation of the centers of an inflammation. From here inflammatory infiltrates spread on interstitial fabric of perivenous spaces, coming to the surface of a kidney, in subkapsulyarny cracks, according to an arrangement of star-shaped veins. In the subsequent pus and bacteria get into a gleam of tubules. An embolic glomerulitis at And. N - the phenomenon secondary.

In a phase of recovery on places of pustules granulyatsionny fabric which then cicatrizes is formed.

Clinical picture

And. the N is observed at any age, is slightly more often at women. Unilateral process occurs at 96,6%, bilateral — at 3,4% of patients. The clinical picture develops of the signs typical for the general heavy infectious process with deep intoxication: headache, febricula, high temperature of constant or remittiruyushchy type, fever. Sometimes these phenomena are expressed so intensively that give a reason to assume an acute infectious disease. Later a nek-swarm time symptoms of local character appear: the pain in lumbar area irradiating in an upper part of a stomach, a shoulder on the course of an ureter or in a hip. And. the N can be followed by bacteriemic shock: sharp deterioration in the general state, pallor of integuments, Crocq's disease, low pulse, falling of arterial pressure, hurried breathing.

At a palpation define morbidity in the affected kidney, a muscle tension of lumbar area and an abdominal wall. Often note sharp morbidity in the field of a costovertebral corner.

Important signs of purulent process in a kidney are the pyuria and a bacteriuria. In an initial stage And. the N of changes in urine can not be since kortikalno the located abscesses only sometimes break in a renal pelvis. Later in urine there are erythrocytes, leukocytes, an insignificant albuminuria and a microhematuria, a bacteriuria (at 85% of patients find more than 100 thousand bacteria in 1 ml of urine).

In blood quite often expressed leukocytosis with a considerable neutrocytosis.

Complications

the Most frequent complication And. N — paranephritis (see).

The most dangerous complication And. N — a septicopyemia at which also other kidney can be surprised. At localization of process in an upper pole of a kidney there can be subphrenic abscess and reactive pleurisy, and at localization in the lower pole — a picture of a psoitis. In cases when abscesses are located preferential on a front surface of a kidney, the peritoneal phenomena and sometimes a picture of an acute abdomen are observed. And. the N can be complicated also by phlegmon of retroperitoneal cellulose.

The diagnosis

the Diagnosis is established on the basis of a clinical picture of a disease and special methods of a research. In recognition of the party of defeat the known help is given by a so-called comparative leukocytosis: the quantity of leukocytes in the blood taken from skin of lumbar area from the affected kidney are, more, than in blood, the lumbar area taken from skin of the opposite healthy side and from a finger of a hand. The new method of a research and diagnosis — a color termografiya of skin of lumbar areas finds application. Termografiya is based on ability of cholesteric liquid crystals to change the color in response to the slightest local temperature variations of a body. Thanks to this method it is possible to establish and specify localization of inflammatory process in kidneys (see. Termografiya ).

At And. N are available the following radiological signs: increase in the sizes of a kidney at 80% of patients, scoliosis towards defeat — at 79%, a smazannost or lack of a contour of a lumbar muscle — at 78%, an illegibility of a shadow of pyelocaliceal system on excretory Urogramum — at 48%, a symptom of an aura of depression around a kidney — at 40%, deformation of cups and a pelvis — at 38%, focal protrusion of an outside contour of a shadow of a kidney — at 9% of patients.

The excretory urography promotes identification of an obturatsionny factor of a disease. On excretory Urogramums in 68% of cases sharp restriction of movements of a kidney or its full immovability at breath of the patient is noted.

Forecast at most of patients And. N bad, especially in the presence of the only kidney.

Treatment

to the Patient carry out intensive antibacterial care, appointing antibiotics of a broad spectrum of activity, streptocides, nitrofurans. Treatment should be carried out taking into account indicators antibiogramm. At suspicion on impassability of an ureter its catheterization is necessary; after recovery of passability of an ureter in it leave a catheter at several o'clock.

At a low-virulent infection development of purulent process in a kidney can stop and there occurs recovery.

In cases when conservative treatment by means of antibiotics and himiopreparat, and also of urine on it does not give to catheterization of an ureter for the purpose of recovery of a passage success, and the condition of the patient continues to remain heavy, an operative measure is shown.

Operation consists in an exposure of a kidney, its decapsulation, in a pyelostomy or a nephrostomy. The largest pustules or their accumulations on the surface of a kidney should be opened, and the found anthrax to cut or exsect. Operation is finished with leading to a kidney of cellophane and gauze tampons. To delete a stone from upper uric ways most of which often is the reason of their occlusion, follows provided that this intervention is easily feasible within the available operational wound (a pelvis, an upper third of an ureter). If the stone is located below and its searches are complicated, then an operative measure is limited to drainage of a kidney. The drainage from a kidney is deleted only at a complete recovery of passability of uric ways. In case of sharply expressed intoxication, the nephrectomy at a satisfactory functional condition of the second kidney is shown to extensiveness of purulent damage of a kidney, existence in it of a multiple anthrax (see. Nephrectomy ).

Prevention consists in timely treatment of extrarenal suppurative focuses, urological diseases, elimination of the reasons leading to disturbance of outflow of urine from upper uric ways.

Cm, also Kidneys .


Bibliography: Panikratov K. D. and Gerusov Yu. M. Use of a color termografiya in recognition of acute pyelonephritis, Urol. and nefrol., No. 4, page 18, 1972; P y t e l A. Ya. Lokhanochnopochechnye refluxes and their clinical value, page 199, M., 1959; P y t e l A. Ya. and Goligorsky S. D. Elected heads of nephrology and urology, p. 2, page 5, L., 1970; Fedorov S. P. Surgery of kidneys and ureters, century 3, page 335, M. — Pg., 1923; Colby F. N of Pyelonephritis, Baltimore, 1959; Progress in pyelonephritis, ed. by E. H. Kass, Philadelphia, 1965; Pyelonephritis, hrsg. v. H. Losse u. M. Kienitz, Stuttgart, 1967.

A. Ya. Pytel.

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