上尿路结石合并气肿性肾盂肾炎五例报告并文献复习

目的探讨上尿路结石合并气肿性肾盂肾炎的临床表现和诊治方法。方法回顾性分析2012年7月至2019年12月北京大学人民医院收治的5例上尿路结石合并气肿性肾盂肾炎患者的病例资料,并结合既往文献进行总结。本组5例,男2例,女3例。年龄40~67岁。1例既往有糖尿病史且血糖控制较差。5例入院时均有发热表现,体温分别为38.7℃、38.8℃、37.5℃、38.6℃、40.0℃,血常规白细胞计数分别为17.2×10^9/L、14.9×10^9/L、11.2×10^9/L、15.1×10^9/L、13.3×10^9/L,中性粒细胞分别为0.90、0.89、0.85、0.87、0.88,均高于正常。尿常规白细胞均>200/μl。C反应蛋白分别为68 mg/L、253 mg/L、9 mg/L、8 mg/L、67 mg/L,其中例1、例2和例5升高较明显。3例有肾功能不全。5例中肾鹿角形结石2例,肾多发结石3例,均伴中重度肾积水。CT检查均提示肾、集合系统和/或肾周有气肿性表现,明确诊断为上尿路结石合并气肿性肾盂肾炎。例3、例4经单纯抗感染治疗,例5行肾穿刺引流术配合抗感染治疗后,体温恢复正常,血常规检查示白细胞降至10×10^9/L以下,中性粒细胞降至0.80以下,尿常规白细胞降至50/μl以下。另2例感染控制不佳,例1接受肾周脓肿穿刺引流术及经皮肾穿刺引流术并配合抗感染治疗3 d后,体温恢复正常,但血常规白细胞始终为(11~12)×10^9/L,多次复查CT提示各肾盏及肾周积脓积气情况无改善;例2留置输尿管支架及经皮肾穿刺引流术并配合抗感染治疗后,仍有间断发热,尿细菌培养为热带假丝酵母菌,加用氟康唑治疗后,体温恢复正常,但血常规白细胞仍为12×10^9/L左右,复查CT提示肾盏及肾周积脓积气情况略有加重。结果3例感染得到控制者行经皮肾镜碎石取石术,例4术后出现发热,抗感染治疗后缓解,未发生其他并发症。2例感染控制不佳者行肾切除术,术后恢复顺利,术后病理检查均提示肾小球萎缩、硬化,肾小管扩张,炎性肉芽组织形成。5例随访1~84个月,血常规、肌酐、CT影像与出院时相比均无明显变化,未出现结石梗阻导致的感染。结论上尿路结石合并气肿性肾盂肾炎少见,但病情进展迅速,治疗难度大,应早期行CT检查以明确诊断,及时留置双J管或行穿刺引流,并配合广谱抗菌药物控制感染,以改善患者预后。

Upper urinary tract calculi complicating with emphysematous pyelonephritis:5 cases report and literature review

Objective To discuss the clinical manifestation,diagnosis and treatment of upper urinary tract calculi complicating with emphysematous pyelonephritis(EPN).Methods The clinical data of 5 cases of upper urinary tract calculi complicating with EPN diagnosed in our department from July 2012 to December 2019 were retrospectively analyzed,and literatures were reviewed.5 patients were identified by computed tomography scanning to upper urinary tract calculi complicating with EPN,3 female and 2 male,aged 40-67 years,2 staghorn calculi and 3 multiple stones.One patient suffered from diabetes mellitus.All cases presented with fever at the enrollment point,and the body temperature were 38.7℃,38.8℃,37.5℃,38.6℃,40.0℃,respectively.And the number of white blood cells and neutrophile granulocyte of these cases were higher than normal reference value,were 17.2×10^9/L,0.90;14.9×10^9/L,0.89;11.2×10^9/L,0.85;15.1×10^9/L,0.87;13.3×10^9/L,0.88,respectively.The C-reactive protein were increased in all of the cases,especially in case 1(68 mg/l),case 2(253 mg/l),and case 5(67 mg/l).And 3 cases with renal insufficiency.Case 3 and case 4 were controlled the infection with medical management alone,and case 5 with percutaneous drainage plus medical management.The pyelonephritis of other 2 cases were uncontrolled,the body temperature of case 1 returned to normal after treated with percutaneous drainage of perirenal abscess plus nephrostomy plus medical management,but the imaging findings of kidney was not relief by CT scan after 4 weeks.Case 2 was persistent fever until treated with fluconazole according to the medicine sensitive experiment’s result of urine culture after undergoing nephrostomy plus indwelled a double J tube in ureter,but the CT findings of kidney grew worse 1 week later.Results Of the 5 patients,1 received first-stage nephrostomy and second-stage percutaneous nephrolithotomy,2 received same session surgery,2 received nephrectomy.There was no complications occurred except postoperative fever in 1 case.Postoperative pathology of the nephrectomy revealed glomerular sclerosis,glomerulus dilation,and inflammatory granulation tissue was formed.And 1-84 months follow-up showed no recurrence in all the cases.Conclusions Upper urinary tract calculi complicating with EPN is an rare acute severe infection,CT is the best choice of early diagnosis,double J stenting or percutaneous drainage of abscess with broad-spectrum antibiotics could be the preferred treatment.