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http://www.kidney-international.org & 2013 International Society of Nephrology Kidney International (2013) 0, 000–000. doi:10.1038/ki.2013.60
Cutaneous fistula from obstructive pyelonephritis Q1
Marine Lochouarn1, Olivier Andreani2, Alexandre Marsaud3, Charles Raffaelli2 and Olivier Moranne1 1
Service de Ne´phrologie, Centre Hospitalier Universitaire de Nice, Nice, France; 2Service de Radiologie, Centre Hospitalier Universitaire de Nice, Nice, France and 3Service d’Urologie, Centre Hospitalier Universitaire de Nice, Nice, France Q2
Correspondence: Olivier Moranne, Service de Ne´phrologie, Centre Hospitalier Universitaire Pasteur, 30 Avenue de la Voie Romaine, 06100 Nice, France. E-mail:
[email protected]
Figure 1 | Skin ulceration in the right lumbar area.
An 86-year-old woman was admitted with failure to thrive and dyspnea and was noted to have an ulcerated skin lesion on her right flank with a spontaneous discharge (Figure 1). She had no significant medical history other than chronic right lumbar pain, self-treated with non-steroidal antiinflammatory drugs. Physical examination was notable for an afebrile patient, with blood pressure of 160/80 mm Hg, bilateral chest crackles, and leg edema. Laboratory tests showed serum urea nitrogen 3.2 mg/dl, creatinine 120 mg/l, hyperkalemia 6.4 mmol/l, hyponatremia 128 mEq/l, venous bicarbonate 10 mEq/l, hemoglobin 7.6 g/dl, and C reactive protein 15 mg/l. The urine dipstick showed the presence of proteinuria þ þ , leukocyturia þ þ þ , blood þ þ þ , nitrite þ þ ; urinary pH was 7.0. Urine and skin secretion culture showed the presence of Proteus mirabilis and
Kidney International (2013), 1
Figure 2 | Magnetic resonance imaging (threedimensional CUBE) shows the complete fistula tract and communication with the calyceal cavity.
Escherichia coli. Abdominal ultrasonography showed extensive staghorn calculi in the right kidney and the renal scan revealed urinary obstruction. Computed tomography scan and fistulography showed an incomplete fistula, whereas three-dimensional (3D) magnetic resonance imaging (MRI) without contrast agent (Figure 2) showed the complete fistula tract and its communication with the calyceal cavity. The patient was diagnosed with nephrocutaneous fistula secondary to obstructive staghorn calculi. The patient refused surgical treatment and was started on hemodialysis. She developed anuria on dialysis and the fistula remained patent with minimal secretion 18 months later. An insidious purulent skin discharge from the flank may suggest a fistula and 3D MRI could be a useful diagnostic tool without the need for contrast agent.
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