CT imaging of acute and chronic pyelonephritis: a practical guide for emergency radiologists
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PICTORIAL ESSAY
CT imaging of acute and chronic pyelonephritis: a practical guide for emergency radiologists Federica Vernuccio 1,2,3,4
&
Diana Patti 4 & Roberto Cannella 4 & Giuseppe Salvaggio 4 & Massimo Midiri 4
Received: 11 April 2020 / Accepted: 4 May 2020 # American Society of Emergency Radiology 2020
Abstract Contrast-enhanced CT is not routinely indicated in uncomplicated urinary infections, but it may be necessary in patients with specific risk factors (i.e., diabetes, immunocompromised patients, history of stones, or prior renal surgery) or in patients not responding to antibiotics and in detecting complications of pyelonephritis. CT is the gold standard for imaging assessment of pyelonephritis severity. Imaging appearance of acute pyelonephritis, including focal (i.e., wedge-shaped zones of decreased attenuation or hypodense mass) and diffuse (i.e., global enlargement, poor parenchymal enhancement, lack of excretion of contrast, fat stranding) forms, needs to be differentiated from renal infarction, renal lymphoma, and interstitial nephritis. Chronic pyelonephritis—which appears as focal polar scars with underlying calyceal distortion, global atrophy, and hypertrophy of residual tissue—may mimic at imaging lobar infarcts. This pictorial essay reviews the CT imaging appearance of acute and chronic pyelonephritis, their uncommon subtypes, and their complications, with key features for early diagnosis. Their knowledge is crucial for emergency and abdominal radiologists to avoid misdiagnosis with malignancy and to guide the clinician towards the appropriate medical or surgical treatment. Keywords Computed tomography . Imaging . Emergency . Pyelonephritis . Kidney
Background The diagnosis of urinary tract infections is usually based on clinical data and laboratory tests [1]. Imaging is not required in patients with uncomplicated pyelonephritis who respond to
* Federica Vernuccio [email protected] 1
Dipartimento Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza G. D’Alessandro, University of Palermo, Palermo, Italy
2
I.R.C.C.S. Centro Neurolesi Bonino Pulejo, Contrada Casazza, SS113, 98124 Messina, Italy
3
Hôpitaux Universitaires Beaujon, Radiology, Université Paris VII, Clichy, France
4
Dipartimento di Biomedicina, Neuroscienze e Diagnostica avanzata (BIND), University Hospital “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy
treatment [2]. Imaging assessment may be necessary in patients with specific risk factors (i.e., diabetes, immunocompromised, history of stones, or prior renal surgery) or in patients not responding to antibiotics and in detecting complications of pyelonephritis [3, 4]. CT is the gold standard for the diagnosis and evaluation of severity of acute pyelonephritis and its complications [5]. Contrast-enhanced CT is needed to define the extent of the disease and identify complications [6]. The recommended CT protocol for renal infections includes a nephrographic phase— which usually begins 80–120 s (commonly 90–10
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