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Renal infections- Pyelonephritis and Beyond

May 28 | 1:30 PM

IRIA Kerala brings you a very interesting session on Renal infections- Pyelonephritis and beyond. Dr. Nidhin James will talk about a spectrum of renal infections from experience along with some important aspects to consider in diagnosing the same. Reporting the various associations and differentiation from common pitfalls would also be covered with the help of a few cases of extrarenal genitourinary infections. Join now for this insightful session!

[Music] uh good evening everyone i am dr tanvi and i welcome you all on behalf of netflix today we are gathered here for a very interesting session by ira kerala on renal infections pyelonephritis and beyond and to introduce the speaker we have dr zunaman do as a number doctor please uh take it forward good evening all right welcome all to the uh uh session of saturdays which we are regularly conducting uh this week we have uh sessions by pushpagiri institute of medical sciences we had a pg presentation on wednesday with uh uh headed by uh expert faculty gina ma'am and good evening yeah yeah good evening i'm very happy that uh we are starting the uh renal system uh with pyelonephritis and beyond by dr niti i am very happy because kerala is doing very well this time and generating ordinary infection is going on so i welcome dr nitin on behalf of kerala uh to give you a talk uh doctor this you is to dr suny moore okay to introduce dr niti who is assistant professor in the department of radio diagnosis kushbachi institute of medical sciences uh he is a graduate from the same institute pushback institute and did a post graduation md radiology in from pondicherry institute and he completed uh after completing the amd radiology course uh he and he did a fellowship in uh cardiovascular imaging also from america institute of medical sciences koji uh here today he is uh talking about the renal uh infections uh though his interest is in cardiac imaging as well as the cross-sectional imaging and also uh i read that interested in ob gynae imaging then non-vascular interventions and he is very ambitious to pursue his career in radio diagnosis and also [Music] interested to contact various faculty talks interested in academic activities uh he's part of many academic programs as in the team in the hosting team that's what i read about him and i welcome you nathan dr nitin james to start today's session will not waste time uh good evening everyone thanks to everybody who's attending this webinar on a weekend so today we will be talking uh in short about the renal infections why renal infections because this is one of the common scenarios we are asked to rule out during emergency duties as well as during routine uh cross-sectional imaging as well as ultrasound uh cases so most of the clinicians wants to first roll out infection first and then think of other things so the very common scenario most radiologists come across so today we'll be discussing uh the various imaging appearances renal infections usually presents with as well as some common diagnostic pitfalls that can be involved and we also uh talk about are we or we are also showing some interesting genitour infection cases that has come across in our department over the past few years so to start with so renal infections are basically uh imaging is not primarily required for real infection so based in on a theoretical term but based on uh usually the diagnosis is based on clinical features and abnormal lab variants patients usually present with dysuria fever flank pain and causal vertebral angle tenderness and textbook says that anything is reserved for people unresponsive to therapy a typical clinical presentation life threatening status and also to evaluate short and long-term complications uh so but on a practical note uh in our daily scenario imaging is the first thing that is that comes uh play when the patient comes immediately imaging is done then usually the lab values and the laboratory investigations are done uh subsequently so yeah renal infections usually let us give me infection usually organics in the urinary bladder and descends to the kidney via the ureter or very rarely arises relatively in the kidney and or see that they are hemogeneously where when hemogenesis the cortex is most commonly involved so whatever the mode of spreading is usually a tubular interstitial inflammatory reaction ensues which uh involves the renal pelvis and parenchyma the risk factors as in the infections of other regions as our diabetes family thermolitis and immunocompromised states leukemia chronic reflex basically euthanic reflux various forms of obstruction and calculate forming diseases so imaging adds very important diagnostic information uh answering the many queries a clinician would want that is the classification and type of involvement of kidney the extension that is whether it's intra-renal extra renal or involving the adjacent organs or viscera or easily even extending outside the body so and then the progress to treatment uh and how it is scene and presence of any congenital anomaly which can lead to subsequent infections and act whether active intervention status is required and the other complications associated with it the usual imaging modalities are x-ray fluoroscopy ultrasound and cross-sectional imaging and plane radiography usually is not routinely done but it gives an important information as to presence of gas and typical type of and pattern of calcification in the region of renal fossa and uh fluoroscopic studies this uh intravenous urogram still holds the ground for uh showing us that various calcium or subtle calcium abnormalities that can develop on very early on so and mr also plays a role in immunocompromised patients patients with deranged renal parameters as well as some areas where ct is equivocal so the ep protocol usually involved involved is a plane study arterial phase the nephrographic and excretory phases so they're coming to a spectrum of renal infections we have acute and chronic uh acute again is uh pylon arthritis patterns such as acute uh pyramid nephritis focal nephritis axis formations emphysema spinal nephritis capillary necrosis and pioneer process whereas in chronic we get uh again chronic pyronephritis xanthogranulomatous pattern of phylonephritis uh conditions such as molecular yes nucleic cystitis and not from the last but tuberculosis and fungal infection fungal infections are usually seen in uh you know hiv uh uh nephropathy associated nephropathy transplant associated and in a compromised state and so let's come to acute pylon to fight this the various imaging occurrences that we see are increased renal size and on ultrasound increased region size the loss of normal cortico medullary differentiation loss of renal sinus fat due to edema dilated adrenal pelvis european thickening perinephric changes uh loss of normal cortical pattern and massless area of abnormal echogenicity or striated type of echogenicity and on doppler sometimes we get areas of hypoperfusion and hyperperfusion is basically because of vasoconstriction because from edema and surrounding inflammation so on this these same findings will be appreciated with much better precision and confidence for the rheologist so again enlargement focal hypo enhancement uh patterns such as stride in a program pseudo nodular pattern and abscess can also occur so why we should diagnose these things is because if i keep filing a fraction it's left for grant taken for granted and left untreated uh and especially and not uh and any obstructive disease especially is uh detected this can lead the euro success or diffuse neurosuccess and rain failure even death so very uh easy thing very easy thing to say but uh this this is a very practical scenario so here we have a 40 year old man who came to ultrasound and was an ultrasound showed diffuse bulky appearing kidneys with increased echogenicity and we can see there there's some european thickening as well along with some perinephric fluid so again some cct was done and european thinking was noticed along with some perinephric stranding uh there is inflammatory changes and some minimal very tender you can see that there is a rim of contrast that is uh and focal enhancing area that's extending from the papilla or middle to the cortex so this again this short stride of nephrogen with the decreased in excretion in the right kidney so again another pattern is of a focal weight shaped or ill-defined area of hypo enhancement with minimal pediatric straining so these are the common imaging appearances that we see and we'll come to a dedicated study so this is one case we had this is of a 70 year old man who presented with uh severe right-sided uh pain uh lumbar pain and on ultrasound ultrasound showed uh very uh loss of cortico-medullary dissociation in the upper region of upper polarity so only saline again and i'm showing only the saline images so these are venous and delayed face images uh which shows a very hypo enhancing unified hyper-enhancing area in the region of upper pole with minimal heterogeneity in the in the center and we can see that in delays there is no expression in that region so i hope you can see the video earth so we can see that there is total pelvis of distortion or not no excretion is seen from the upper part of right kidney with some minimal period effects finding so this is a pattern known as lobar nephronia uh usually associated with early access formation so the heterogeneity in the center usually uh such as some early abscess formation but not exactly a true abscess as you can see however this will look so this robot nephron is a stage of nephritis and uh it's an intermediate stage between uh acute nephritis and relapses so interstitial nephritis is a pathological uh appearance uh presentation so this is another case uh here we have uh venus and delayed face images of a of a 40 to 45 year old man he presented again with uh he was presented with the recurrent urinary tract injections so uh after multiple iv antibiotic therapy this patient was taken up for ccp because of unresponsiveness and here we can see that there are patchy areas of local areas of hypo enhancement involving the lower pole and part of upper pole but with intervening normal areas of normal intervening normal enhancing tissue in between so this is a delayed face image again showing this finding with much more uh conspicuity and you can you can see that there are areas of uh hyper enhancement in between uh in between hyper enhancing areas so this is a pattern uh consistent with a striated nephrogram unknown standard deviogram so this is an appearance more uh describing expected that shows uh discrete rays of alternating eating from the papilla to the cortex along the direction so this pattern is again ascribed to the decreased flow of contrast and eventual stasis and the hyper concentration the edematous or necros tubules involved so against phytonitrogram is not it's not typical or diagnostic of this infections or nephritis it can be seen in a lot of other conditions so metal pattern is usually seen with violent disease obstruction adrenal vein thrombosis even for trauma conditions can show this acute radiation therapy to the kidney the radial infection and transition cell carcinomas bilaterality is seen in again infections uh autosomal drugs this is polycystic kidney disease acute tubular microsis hypotension acute tubular obstruction idiopathic asymptomatic uh in some children brain infarction and contrast associated acute kidney injury so a common pitfall here is differentiating this uh pattern from renal infarction and and uh how to differentiate this from viral infection so as the infection offers infarction so focal phobia pylon nephritis is usually a they show some some form of delayed some minimal delayed enhancement and there is no presence of some uh something called there's no particles inside whereas in segmental infection there is something called cortical rim sign where there is some rim and has cortical rim enhancement in the periphery due to extra renal arterial capsular supply seen commonly in acute vascular obstruction but here we don't have delayed enhancement there will be no absolute no enhancement within the wedge of infarct involved coming some examples so this case yeah the first case is a case which shows uh delay uh face images of a patient who has who came for a repeated contract where this patient had a contract done about two days back for to roll out acute pulmonary embolism and this patient and now since patients complain complaints complained of severe abdominal pain and the cct was done so here are the delete face images we can see that there is alternating areas of hypo and hyper attenuation in bilateral kidneys in a very symmetrical distribution so this is basically uh because of retention of contrast within the necro tubules and patients after the first again all these patients created rapidly shot up from about 1.4 to 3.2 so this is a case of contrast induced nephropathy the second case again shows uh as it's already labeled here again shows any uh you'll define the area of focal hyper enhancement with the presence of a cortical uh rim sign almost defined almost over shaped area uh but you can see that there's a linear a line of curvilinear lines enhanced machine at the periphery so this is the cortical room science so this is uh this is case of acute regulatory occlusion again we can see almost a red shaped area of hypo enhancement with a decent focal perinephric stranding and addition parallel facial thickening and here we don't see any cortical concern so this is okay again in case of acute bile nephritis so this is again a case uh uh 60 year old lady she presented with uh which is actually a case of breast carcinoma undergoing chemotherapy so this lady uh presented with a sharp uh loculated pain involving the uh left side and came to the year so patient on year uh here people here since ultrasound was done outside and did not show any significant changes only some focal area of uh like ill-defined area hypertension in the upper pore of left kidney otherwise so cnc does advise in cct as we can see showed a peripherally rim enhancing central hypodense area uh these are the venous images in the upper pole of uh left kidney and this is seen extending outside the kidney and outside the confines of normal kidney into the adjacent perineusic region and as well as butting the lower pole of spleen so this again is a case of splenic renal abscess that is seen in the left skin that is extending outside into this plane uh outside into the peninsula area and as well as a clinical explain so we have a complication of uh typically complication of relapses so this is a with relaxation extension is the case and renal apps is basically means necrosis of the renal parent and it's a common complication of focal pyloritis as well as hematogenous infection usually seen as focal area in unilateral kidneys and about twenty percent of the time uh the urine cultures can be negative because the pelvic helical system may not be involved so the complete common complications are basically because of its extension outside with the parent effect subdiastematic and pelvic regions and associated furthermore of the disease or it can lead to even severe euro sex so early access appears as a area of poorly marginated non-enhancing area of decreased attenuation whereas a mature abscess and even olesis can even resemble a system ultrasound so mature abscess appears as sharply marginated uh complexistic mass with necrosis and a peripheral enhancement so usd may trading level of complexity involving dense echoes acceptations and locations and your posterior acoustic shadowing or post-acoustic enhancement can be uh dependent on this level of on the level of complexity so mri here the diffusion sequences in mri can really pick up access showing restriction uh like in other parts of the body so in a transplant patient again diffusion has an important role to play as another contrast is contraindicated due to deranged rhino parameter here we are again seeing a mature and yes ma'am or your network uh i think there's a network problem your voice is cracking oh okay are you able to hear me now clearly yeah yeah it's better okay thank you so uh yeah so second image is a contrast image again showing uh peripherally enhancing uh centrally high potency non-enhancing areas with adjacent inflammatory changes so so again internal complexity again sometimes is seen by number amount of certifications and the amount of debris we see so peripheral enhancement with central hypotenuse areas such as abscess like anywhere else in the body and we have to make a note of the different levels of complexity it provides so this is again a case whereas a 70 year old lady she presented with a sudden onset lumbar pain radiating actually a lumbar radiculopathy presentation so this patient came to emergency department and and on ultrasound we found a an exophytic mass involving the left so as bundle so immediately uh contrast c2 is advised and uh contrast was done so this image again venus and delayed phase images showing we can see that the left kidney here is very hypo enhanced compared to the right kidney and there is significant european thickening and enhancement of the electric walls along with some hydronephrosis and coming down and in the region of uh psoas became an exotic peripherally enhancing high powered and centrally hyped region with adjacent inflammatory changes so these uh axial images showing uh significant uh eutrophic in hand like significantly highlight is that spinatus is the environment of ureter with circumstantial neural thickening and neurothelial hyper enhancement and periodic stranding and sometimes even collections can be seen outside so here we can see that the ureter is going into the region of uh so the into the exophytic lesion that we described earlier in the psoas which is peripheral enhancing with general hypodensity and a lot of loss of definition there in the normal anatomy so this again was a case of psoas abscess that ruptures uh into the soil assets that is involved so it's absolutely involving the uh ureter so this is again a case of outside infection extending inside now coming to another prospect of resolution known as pioneer pioneers so pioneers is nothing but us within the collecting system in simple terms so this is infected hydronephrosis as the integrative destruction of the radial parenchyma with partial of total loss of function again so accumulation of coral and debris and sediment in the real pelvis and collecting system is usually seen and is usually associated with factors that compromise the host difference including immunosuppression renal failure and renal transplantation this is associated with the local factors that compromise the urinary tract such as congenital europa the neurogenic bladder pregnancy presence of foreign bodies calculate indwelling catheters other drainage devices or endoscopic manures and it is frequently associated with obstruction of the collecting system so here we go images of uh various cases uh i'll just run findings instead there's market hydro nephrosis with heterogeneous heterogeneously ecogenic content that are seen within the collecting system and uh there is some minimal perineus like uh hyperechogenicity and uh suggestive inflammation along with some minimal flow with balloon effect fluid so varying levels of complexity as we can see can be seen even involving with pioneers separations and even mass-like appearances can be seen within the collection system so again uh ccp may just shows a significant euro till thickening with the adjacent uh psoas region showing multiloculated very freely enhancing areas uh representing collections so on delete these images we could view there was there was extravasation of the kelly cell contrast into the region of psoas suggested cortical necrosis and particular ankylosing necrosis or abscess relaxation of the anatomy so this is another case only plane images are seen yeah patient chronic renal failure because of repeated urinary tract infections here we can see the left side of kidneys kind of appearing like a boggy mass with the loss of normal anatomical definitions you know and presence of air within the same and we can also see the multiple air foci in the para renal region as well as well as within the urator now this is again a similar case where we have here we have bilat you know he's of air within the collecting system predominantly within the collection system and uh it's kind of distorted in anatomy started in its cortical line cortical shape a normal tiny form shape and bilateral djs are also seen in the collecting system so here you can see that the significant amount of air and there's a significant ure you reach toward thickening or european thickening and very natural castle is very urinary stranding so air within the collection system uh should uh you know make us think first of nothing other than emphysema spiral difference it's not a very it's not really uncommon pretty commonly seen so fascinating spider nephritis is a life threatening necrotic infection with gas formation within the cortex and or within the collective system commonly seen with chronic diabetes chronic utis and states so presence of gas is usually attributed to the fermentation by gas producing organisms in the presence of high glucose levels and usc usually shows non-dependent echoes dirty shadowing but whereas but small focus that can be missed on understand it's not very diverse so uh ct is the modality of choice showing the severity the extent the loss of normal anatomy and fluid like presence of fluid collection or abscess formation nah within the region temperature smallest pyloritis is broadly classified into two types type one and type two type one is the wet type and type type one is a tripod is a dry type and type two is the white type uh so type one we don't have any collections and more than one third of the current chemical destruction is seen but here the mortality rate is pretty high and usually refractive is the treatment of choice and there's no fluid cut fluid or post collagen steel in this type because of reduced immune response in this region and type 2 usually has period renal or intrarenal fluid collection that is characteristic and aggressive medical treatment with percuta along with you know coupling with cutaneous drainage can uh give some relief or uh even full even curate even complete cure so here uh type 2 usually less than one third of the span so another classification usually followed is the anatomical classification which shows the based on the extent of the disease are very commonly a very famous classification like wong and same so therefore classified into four types class 1 is usually gas or present only in the collecting system and class 2 is basically air involving the [Music] parent involving parenchyma uh as a pancake as well and class three is again divided into two types a and b where there's perinephric and paranormal extension class four is usually uh all risky case based if there is some personal spirit and effort involving only a solitary kidney or bilateral disease so the type three and type four uh usually if there are more than two risk factors chance of patients going to renal failure even with perturbativeness range and antibiotics is about 92 percent some common complication again this is a case uh ct images showing the uh inflexible spinalitis and cystitis the presence of air in the collecting system as well as uh within the bladder here what we have to see is in there and especially in the absence of uh bladder wall instrumentation so so emphasis is usually accompanied by obstruction due to calculus neoplasm or any structure or any of these obstructive europa and usually uh patients are all diabetes so even cystitis emphysema status can may not then you know that their is seen only within the blood it can be seen very commonly within the blood of walls also so this is again not a case of a really infection but since a genital urinary topic is going on this is again a common complication where uh you know we can see uh if uh this infection is extending to the other parts of the intraunity system uh this is a 50 year old man uh which we can see that the coronal and sagittal cuts in the delayed and venus phases it shows almost loss of normal anatomy involved in the region of seminal recycles and prostate with multiple air lock tools as well as peripheral rim enhancing area of fluid collection so imaging was consistent again with the diagnosis of emphysema as prostatitis and uh and seminal west collapses just another uh common extent complication due to extension of the same so in india we do not uh talk about infections not talk about tuberculosis so why rainy tb it is the most common extra pulmonary [Music] and gently your nervous system which is the most common circuit it's the most common site so an appearance is such so vague and so huge that as same appearances as we discussed earlier can show varying from all the way from nephritis to uh you know emphysis formation pioneer process uh structures and multiple calcium abnormalities and so on so this is a wide spectrum and one of the great limiters again so i'll be running through some of the common uh salient imaging appearances that are seen commonly associated with different imaging modalities so uh findings can involve the collecting system or the parent kind of findings involving the collecting system are usually because of depending on the stage of the disease early stages can show popular necrosis involving the calluses or chemical system which can involve one calyx or multiple calluses leading to an even prominent finding called uneven calculus we see very commonly in intravenous urography so progressive stage again can can lead to multifocal structures involved in the calcium system hydronephrosis neural thickening enhancement and end-stage again disease give progressive hydronephrosis parametering dystrophic calcifications as well as autonomy again so findings involved in the parenchyme are pilots uh similar to other organisms similar to other patterns and organisms we just discussed earlier so here again renal hyper perfusion and swelling can occur because of severe nephritis and vasoconstriction and pseudotumor type can occur where multiple where the the real paranormal cortex shows multiple of single nodules and can sometimes make rccs and these nodules are nothing but granulomas as you know granulomas or cases areas are leading to cavity formations and so on so coming to plane radiograph and fluoroscopy images so the first image you can hear we can see the typical low bar pattern of calcification that is involved in uh uh reality the case and some amount of urethra calcifications can also be seen so this lower pattern of calcium is very classical a typical tv and most like an almost seen in end stage regular distance rotten reflecting is another case you can see that i view images that this technique is almost non-functioning and the lower pattern of calcification it's very clearly seen here modern predominantly the upper and with old regions uh and there's no excretion as you can see very very minimal expression we can see from the lower aspect of the right kg another the third picture uh shows uh a lot of focus of calcium cortical uh time chemical will define calcification within the region of cortex and such as calcium blunting and some amount of calcium cast formation or this also known as pseudo calculator need not be because of tb it can be because of previous other renal infections and even tuberculosis says you know it is very commonly seen associated with other infections you know as a patient's post defense system is totally compromised so a lot of other infections and diseases can occur at this time and very commonly seen as treated with other pathologies so again these are ibu images uh again showing kelly cell you can see the total distortion of the callus with some kelly cell dilatation and uh these are areas of papular in a process when you can see that the lateral margin of the calyx is kind of irregular and it started so very ragged appearing calyx here and areas of again bachelor in across the scene second image as well with some areas of cortical round nodular areas representing cavities so these cavities can be small as well as big and as as it grows it will erode on cause necrosis of the cavity of the parent timer and leading to finally leading to kelly cell communication this is against scene iv images which shows uh a large cavity that is seen to be communicating with the upper calyx upper compound calyx so this is the margin of the upper compound calyx we can see and this is seen in direct communication with the upper calyx we can see even the other calluses the the margins are not very very clear it's kind of blunted you can see very defined areas of contrast and contrast that are communicating with the lower calyx so these are areas of uh cases necrosis that are communicating with the calyx and some amount of contrast extravasation may be considered here so this arrow again now points to the renal pelvis of the kidney and you can see that the ring pelvis is pulled up and there's a classical appearance seen in tuberculosis known as hyped up cranial pelvis where we have uh you know the spell distilled pelvic structure and the satellite retraction of the proximal pelvis something called hike the brain will pelvis and sometimes the calcification upward pointing calculator again sometimes you see in plane films again suggestive of hyped up renal pelvis in eye view images uh showing calcium and infundable structuring and stenosis with again high depressed pelvis and some significant uneven kelly cases involving the other calluses as well as uh uh loss of uh normal calcium uh anatomy we can compare it with the opposite side we have a good calcium anatomy and here also in on the but whereas you know on the other side left side you can see that there are actually uh extraversation of some contrast from the lower lower half the chemists so this is again suggestive of sinus extroversation and again in a case of delayed phase of ivu uh showing uh on the right side showing papillary across that ball the classical ball and the appearance ball and p appearance so on whereas on the left side we have uh very early developing low bar cassiation uh involving the uh upper aspect whereas in the lower aspect we are seeing significant hydrocalycosis and very assimilation of assimilation of total in combined assimilation of our dilated calluses and parenchymal uh pattern is somewhat same so this uh i think we can also see some calcified lymph nodes in the parabolic region so so ragged hydrocalicos with some significant thickening as we can in this image uh the image showing severe pelvic narrowing with some infundable stenosis of the lower calyx and we can see that a cavity seem to be communicating with the lower calyx but the middle calyx up here appears to be missing so this is a case of phantom calyx that the galaxy is totally destroyed and uneven characteristics can be seen also involving the upper pole region so this again is the case of renal tb uh delayed uh nephrographic phase images actually showing a case of auto nephrectomy or subtotal autonomy where we can see a low bar pattern of calcification involving the upper pole uh predominantly in the region of upper pole and on delete face some some amount of contrast which you know seen from the lower half so low bar pattern of calcification again is typical for tb but what we have to differentiate is some from something called putty kidney the putty kidney again is defined as an area mild uh homogeneous uh density which is more than one centimeter we have articles that says that you know mild uh homogeneous density of more than one centimeter can be uh described or can describe to the pattern whereas in low bar calcifications their significant peripheral low bar pattern of rim calcifications significant pedal rim calcifications are are seen so here again we can see some defined calculate focus in the right psoas region so again these are ultrasound images so ultrasound again shows varying spectrum of fines varying from it can appear as a simple db cases can appear as a simple system really simple system to gaining levels of complexity so this is the same area of simple system we have granuloma formation within the kidney and uh and this is again a case assist with significant was more precision and there is significant you can see the extraordinary extent of the disease with you know the cortical from enhancement in the abscess the perinephric stranding the the electroplating and facial thickening and the multiple paratic nodes and we can also uh see if this disease process has involved any other near this era so this is again again a case of chronic renal tuberculosis uh showing significant scarring and loss of parenchyma in the left kidney uh there's almost complete loss of pain coming out in the mid and mid zone or midpole region with uneven carry cases and significant euro truck wall thickening [Music] multiple uh vocal focal scarring and almost and delays there's no we can see there's no excretion scene compared to the opposite side from this this kidney so it's a completely scar almost a area of multiple focal scarring you see in this kidney with the changes as mentioned so coming to uh that princess end of rainy tv and now coming to another case this is again uh seven year old man uh dead for uh reckon and new ti and uh patient came for uh follow-up because patient still had some amount of uh uti on neuroentrepreneurial examinations so the european responsibility so you know why you can see this complete almost distortion of normal adrenal anatomy involving the lower polar lower half of the electricity with significant at this european thickening and the real cortex and calcium systems appears to be replaced by multi-loculated peripherally enhancing collections with some few specks of fault calcifications so so this was again uh described initially thought of as present appearance of renal abscess but this appearance typically points us to some diagnosis that actually we'll be discussing in the next few slides so this multi lock sometimes the rim of tissue can be seen in the periphery so those are delayed trees images again usually shows uh no excretion there is no exclusion from the involved in the lower half of the almost from the north calyx the lower character of the left kidney stranding and few specs of calculation are also seen so uh we've been discussing one more case a similar case with uh uh chronic renal failure due to obstructive uh europathy so this case again uh shows us a number a large staghorn like calculus within the pelvic significant perinephric inflammatory changes and significant asymmetrical loss of uh cortical parenchyma involving the right side and we can see that cortical pattern is symmetrically thinned out and multiple uh fat density areas are seen replacing the region of pelvic helical system and cortex so these two cases are uh cases of pieces of enzyme something called xanthogranulomatous phytophthora so it's again not very uncommon meaning yellow is described to the yellow color scene in pathology in grass specimen and grass technology so xanthogrylomatosis is a severe form of parent chemical inflammation that occurs in the presence of chronic obstruction as well as suppression uh so replacement of the normal radial parenchyma with multiple fluid cavities arranged in hydrogen pattern is seen commonly as x delays human and almost always unilateral so e coli and proteus mirabilis is the common organisms involved so all the factors of chronic current utis chronic ischemia lymphatic blockage nephritic ineffective pharmacotherapy immunocompromised states and abnormalities metabolism so uh cpu again is the moderative choice because we need to know the extent of disease and the status of the tissues involved so again this is a great imitator can even sometimes mimic adenocarcinoma or tccs and uh pioneers and regular abscesses so usually there is normal renal outlying is lost and uh and last with paradoxically contracted unique pelvis a diffuse pattern is commonly seen sometime but focal patterns can also be usually a difference in common patterns can also be present so paradoxically contact with regular pelvis is seen and almost always on calculus or a pelvic calculus present and obstruction is is very commonly almost very commonly seen in zynthogenometric spinal cord so bear paw sign is a classical sign described on contra city images where calluses are dilated and giving a multi-operated appearance and sometimes most of the lines are removed issue is seen surrounding it the surround is surrounding the fluid field cavities so the complications are same as others and to extend outside and treatment of choice is usually nephrectomy as the areas are usually non-functioning so coming to another composition of chronic phylonephritis that is a renal replacement lipomatosis as we discussed in the second case just earlier replacement like metals or fiber or light ripen diameters can occur in two forms with sinus it can be renal sinus lipomatosis or uh replacement lipometers are replacing liposuction so fiber fatty tissue replaces the regular parent gamma that is atrophied because of chronic inflammation and kidneys usually enlarged with fibrous fatty tissue and the cortex will be really very very tender but commonly the uniform shape of the kidney is maintained again there's a case showing almost complete left some kind of structure in the scene in the but we can see that very thin form of tissue is seen in the cortex so we have second case had significant uh lipomythosis involving the prominent predominantly involved involving the sinuses but uh you know some areas of the car technical progress hopefully i mean this for the patient might progress into the renal replacement light compressors coming some rare uh areas a rare conditions this is a condition known as malecoplegal plaque is a chronic granulomatous condition it can involve any part of the body but usually involves the common site is bladder so this is usually seen as a case of in most of the time it's internally detected not even suspected uh usually presents as iso to my uh hyper quick uh mass of polypoidal or fluffy masses and ultrasound in the bladder and can cause very asymmetrical bladder or tickling and obstruction of eug and uh basically symptoms are usually associated with that and sometimes like it can get very aggressive and cause bone erosions it's a chronic granulomatous condition and nanopathology microcut my caloric gatman bodies are the classical finding they found with multiple leukocyte and lymphocyte infiltration so this is again a case 55 year old man was a known case of uh pulmonary tb presented uh with abdominal pain and so just plain and contrasted was done and playing images uh was shown in the play images shows that there are the bilateral adrenals they're really bulky and with subtle heterogeneity seen within the body of adrenals and we can see that the normal shape of heterogeneous is lost so very bulky appearing adrenals and contrast was done and venus you see me just axial images showing very separated or peripherally reminiscent adrenal antigens which are very minimal central enhancement so so this again uh venus sampling was done uh elsewhere and so on follow this case was diagnosed with the adrenal tv this is the case again we had a similar case with the man uh presenting about a six-year-old man presenting with similar appearance or similarly bulk apparently these few months later so this case again shows again called key or similar apparent kidneys uh with almost adrenals appearing uh near symmetrical and isotonic and contrast axial cts were done and here we can see that the shape of the room is somewhat maintained compared to the previous case and here we have multi-separated enhancement with peripherally uh peripheral multi-separated enhancement so on further investigations i'm not going to the details how the evaluation and multiple other investigations this was a proven case of adrenal histoplasmosis so again histoplast and tb are very common organs affecting the adrenal gland so again showing some of the complications involving genetic nervous system infections uh so we can see that uh this is again a 70 year old 20 75 year old man showing very uh significant uh focal bladder platter with some high potentiation between and on contra city this was showing peripheral drug enhancement and you can see that there's a mildly enhancing tract that is seen connecting to the adjacent colon with some zero silicon involving both the surfaces so here we can see uh diode including the sigmoid colon and with some decent uh pedicle expanding the ransom anterior abdominal wall collection is also noted and we can see that uh this collection is seen communicating with the uh adjacent sigmoid uh whereas but the sigma but no obvious uh contrast uh active contrast uh extravasation or anti-contrast uh environment was the extension of c into the bladder so this contrasts you've seen because of the delay trees images so again fistula formation is a very common uh presentation in renal and genital urinary infections it can be can be called we can have very levels of fistula it's called a cycle uh you know rectal cycle uh chordo renal uh we can sort of splenic capsules uh uh rain lashes extending into the spleen and you retrieve color polyurethane etc so coming to the last case for today uh it's pretty not a common uh finding at least i have not seen it very commonly so this is an mri images d25 suppressed images showing significant uh uh there's a 40 year old man actually presented with i see the known case of recurrent uti present almost about four to five years of uta was a patient had recurrent episodes of uti being treated behind hospitals and here we can see that on mri uh because of the arranged uh listing uh real parameters mri was advised so mri and t2 images again showed uh some significant european thickening and some period of extending and coronal eurogram images we can see that there are significant cortical scarring involving the whole region and some cyst formation and if you see that there is a right persistent and this patient had right hydrophobic just persistent almost for one year and uh hydrogen right we can see the right pelican system and ureter is dilated and subtle uh t2 hypo intense projections can be seen from the uretric wall so again uh these are eurograss camera urographic images here we can see that the subtle polyphoidal uretric projections seen from the extending from the ureteric wall so this is again a rare complication of or chronic uti where this is known as urethritis or polyurethane cystica these are nothing but cystic metaplasia of the submucosal glands present in the euro record it can be seen involving the operating system also and it can be seen involving the bladder where it's called uh bladder wall as well and other parts of the collecting system again this is another rare complication so to conclude over the years different imaging modalities have been used for inner infections uh just evolved from fluoroscopy ultrasound to cross-sectional imaging so ultrasound is often the first morality of choice we see patients these days and which this shows and various patterns has to be picked up and definitely contra city has to be done because to differentiate it from multiple various and various pitfalls that can impair the diagnosis so one must be able to recognize the various patterns and presentations of infections of course laboratory investigation and clinical uh investigations help a lot and knowledge of pitfalls also should be known so thank you i would like to thank uh my department h.o.d benjamin and the department of radio diagnosis christian medical college and the ira for giving me this opportunity to talk uh to present this topic i would like to see everyone in the future again thank you yeah thank you doctor nathan uh fantastic cases actually i have not seen policy uh uh that uh stick up that multiple lesions which is causing feeling defect polypoid yeah very difficult to find cases this case actually was from the say this was actually from the net molecule look even i have not seen okay okay and really it was wonderful that this is a teaching session so all the infections you have shown from uh the kidney urethra bladder even you showed the abscess that is uh seminal physical abscess air pockets and prostate abscess that's very very wonderful yeah very good thank you so much for segmenting there is also one perspective yes and you know but that is usually seen in immunocompromising hiv that's again a very large topic it's highly associated in a compromised nephropathy yeah that's correct but in that sigmoid diverticularis which you showed now which is pouring the contrast was leaking into the bladder was there any there was no communication there was no uh it was active i was not seen in the involving the brand there was a track uh scene that was seen and it was inflamed and enhancing but but active tracking was seen only within the anterior abdominal wall connection okay okay thank you so much uh dr nitin for presenting for kerala and we have one good faculty with us so you're again we'll be calling you for some other sessions also over to you thank you so much uh your session uh especially as you were showing the cases and discussing thank you compliment for uh being with us and listening to each and every case thank you although shanna is available to me uh thank you and all the participants thank you i think there are any uh relevant radiology relevant questions some uh regarding infections treating like antibiotic uh regarding the uh means antibiotics nitrogen treating infection one question i saw and how to treat hydronephrosis that was one question but uh i don't think uh like that has to be addressed and uh no for no other radiology related questions or doubts we've seen so shall we end up uh today's session once again i thank dr maybe we'll meet up thank you thank you sessions thank you thank you good night everybody

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