Pyelonephritis

KEY FACTS
Genitourinary

TERMINOLOGY • US frequently performed to search for associated

• Acute infection of renal parenchyma; often difficult to complications (abscess, stones, scarring), congenital
clinically distinguish from lower UTI anomalies, & hydronephrosis

IMAGING CLINICAL ISSUES

• Imaging work-up of UTI controversial • Symptoms nonspecific: Malaise, irritability, fever,
abdominal/flank pain, vomiting, hematuria, dysuria, change
○ See professional society guidelines
in urinary habits/enuresis, strong-smelling urine
• With pyelonephritis, marked inflammatory response to
• Treatment: 7- to 14-day course of antimicrobial therapy;
renal parenchymal infection causes swelling that alters
may be started IV & changed to oral
normal tissue properties & effectively ↓ radiologic contrast
agent delivery to site, which results in ○ Obtain work-up for vesicoureteral reflux (VUR) &
congenital anomalies
○ ↓ uptake on nuclear cortical scan
– Pyelonephritis associated with VUR in ~ 25-40%
○ ↓ perfusion on Doppler imaging with altered
echotexture on grayscale US • Complications: Perirenal abscess, necrotizing papillitis,
pyonephrosis (obstruction), & cortical scarring
○ Striated or wedge-shaped foci of ↓ enhancement on
CECT/MR ○ Permanent scarring more likely < 2 years old
• US with Doppler least invasive & readily available but less ○ Recurrent infections & scarring can lead to hypertension
sensitive than nuclear renal cortical scans, CT, & MR &/or end-stage renal disease

(Left) Transverse US of the mid

right kidney ſt shows a focus
of increased echogenicity ﬇
with loss of normal
corticomedullary
differentiation, typical of
pyelonephritis. (Right)
Transverse color Doppler US of
the same right kidney ſt
shows decreased perfusion ﬇
in the area of pyelonephritis
due to marked swelling &
inflammatory response.

(Left) Coronal CECT image in a

13 year old scanned for
possible appendicitis shows
focal decreased enhancement
ſt in the left renal lower pole
with adjacent fat stranding,
consistent with pyelonephritis.
(Right) Posterior pinhole
images from Tc-99m DMSA
renal cortical scintigraphy
show absent radiotracer in the
lower pole of the right kidney
﬊ in a patient with acute
pyelonephritis. Large, wedge-
shaped photopenic areas
suggest pyelonephritis, while
smaller, crescent-shaped
cortical defects suggest
scarring.

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 Pyelonephritis

Genitourinary
TERMINOLOGY Renal Neoplasm
• Well-circumscribed mass, typically round & large
Synonyms
• Acute lobar nephronia, focal bacterial nephritis PATHOLOGY
Definitions General Features
• Acute infection of renal parenchyma • Etiology
○ Renal infection may occur via ascending route from
IMAGING vesicoureteral reflux (VUR) or by hematogenous spread
General Features – Associated with VUR in ~ 25-40%
• Best diagnostic clue
CLINICAL ISSUES
○ Inflammatory response to renal parenchymal infection
causes swelling with focal ↓ in blood flow & delivery of Presentation
radiologic contrast agents • Most common signs/symptoms
Ultrasonographic Findings ○ Malaise, irritability, fever, abdominal/flank pain, vomiting,
hematuria, dysuria, change in urinary habits/enuresis
• Grayscale ultrasound
• Other signs/symptoms
○ Localized or generalized swelling; unilateral renal
○ Strong-smelling urine in any age
enlargement may be only clue to pyelonephritis
• Laboratory studies
○ Poor corticomedullary differentiation with focal areas of
↑ or ↓ echogenicity ○ Urine dipstick for nitrite, leukocyte esterase; both
associated with higher likelihood of positive urine culture
○ Occasionally, rounded or mass-like areas of altered
echotexture noted ○ Urine for Gram stain; Escherichia coli causative in > 80%
of 1st-time UTIs, Klebsiella 2nd most common
• Color Doppler
– Urine specimen for culture: Catheter specimen, clean-
○ ↓ perfusion noted in areas of pyelonephritis
catch midstream, or suprapubic aspirate
– Power Doppler US improves accuracy & sensitivity
– Urine culture considered positive when single
○ ↑ resistive indices (not specific)
organism grows as follows
CT Findings □ > 1,000 colony-forming units (cfu)/mL for
• CECT suprapubic aspirate
○ Wedge-shaped areas of poor enhancement □ Or > 10,000 cfu/mL for catheter specimen
– Enhancement may be striated □ Or > 100,000 cfu/mL for clean-catch midstream
○ Inflamed parenchyma can be mass-like specimen
– Can distort normal renal contour & appear as partially ○ Bloodwork: Leukocytosis, occasionally positive blood
cystic neoplasm during abscess development cultures as well
○ Inflammatory changes in perirenal fat • Complications
○ Renal or perirenal abscess, necrotizing papillitis,
Nuclear Medicine Findings pyonephrosis (obstruction), & cortical scarring
• Tc-99m DMSA or glucoheptonate for renal cortical scan – Recent study found that 1/2 of all patients with acute
○ ↓ accumulation of agent, typically in wedge-shaped pyelonephritis went on to develop scarring
distribution that points toward renal hilum – Scarring may be greater in younger patients
– Findings persist for up to 6 weeks
Natural History & Prognosis
– No volume loss until scarring ensues
• Excellent (in absence of complications or recurrence)
Imaging Recommendations ○ Renal scarring from recurrent infections may lead to
• Best imaging tool hypertension & chronic renal failure
○ US with Doppler readily available & least invasive but less Treatment
sensitive than nuclear renal cortical scans, CECT, & MR
• 7- to 14-day course of antimicrobial therapy; may be started
○ US frequently performed to search for associated
IV & changed to oral
complications (abscess, stones, scarring), congenital
anomalies, & hydronephrosis • Imaging work-up for VUR & congenital anomalies
• Prophylactic antibiotics for VUR & other predisposing
DIFFERENTIAL DIAGNOSIS conditions controversial

Renal Infarction SELECTED REFERENCES

• Wedge-shaped pattern of ↓ perfusion 1. de Bessa J Jr et al: Antibiotic prophylaxis for prevention of febrile urinary
• Retained thin rim of capsular enhancement tract infections in children with vesicoureteral reflux: a meta-analysis of
randomized, controlled trials comparing dilated to nondilated vesicoureteral
• May see abnormalities of vessels reflux. J Urol. 193(5 Suppl):1772-7, 2015
Renal Scarring 2. Morello W et al: Acute pyelonephritis in children. Pediatr Nephrol.
31(8):1253-65, 2015
• Associated cortical volume loss & dilated calyx 3. Narchi H et al: Renal tract abnormalities missed in a historical cohort of
young children with UTI if the NICE and AAP imaging guidelines were
applied. J Pediatr Urol. 11(5):252.e1-7, 2015

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