Vol.:(0123456789) 1 3 International Urology and Nephrology https://doi.org/10.1007/s11255-018-1886-x UROLOGY - LETTER TO THE EDITOR Pyeloduodenal ﬁstula complicating xanthogranulomatous pyelonephritis Maude Laberge 1 · Girish S. Kulkarni 2,3,4 · Boraiah Sreeharsha 3 Received: 15 March 2018 / Accepted: 4 May 2018 © Springer Science+Business Media B.V., part of Springer Nature 2018 Introduction Xanthogranulomatous pyelonephritis (XGP) is a rare and severe form of pyelonephritis, generally treated with nephrectomy. We report a case of XGP complicated by a pyeloduodenal ﬁstula in which conservative medical treat- ment was successful. Case report A 28-year-old, otherwise healthy female experienced a 5-month history of right ﬂank pain and symptoms of cystitis. She had initially received multiple courses of empiric anti- biotic therapy, which proved unsuccessful. An ultrasound performed 3 months prior to her presentation demonstrated multiple calciﬁcations up to 25 mm in size with suspicion of a possible staghorn calculus. While awaiting endouro- logical consultation, she developed fever, nausea, vomiting, and symptoms of a lower urinary tract infection leading to ER presentation. Further questioning revealed symptoms of renal colic. The patient was tachycardic (HR 111), febrile with cos- tovertebral angle tenderness and an otherwise benign abdo- men. Results of blood tests found a normal creatinine at 76 and a white count of 8.7. A non-contrast CT scan of the abdomen and pelvis was conducted and revealed a 3-cm abscess, moderate hydronephrosis, evidence of gas within the kidney, and a 1.6-cm renal calculus. She was diagnosed with focal XGP (see Fig. 1). The contralateral kidney was normal. She was admitted to hospital for percutaneous abscess drainage and a nephrostomy tube. During the procedure, contrast was found to pass through the collecting system into the bowel, demonstrating evidence of a ﬁstula to the duodenum. The ﬁstula was conﬁrmed (Fig. 2) and localized between the right renal collecting system and the second part of the duodenum on contrast CT. Bacterial cultures were positive for Escherichia coli and the patient was treated with ceftriaxone and Flagyl intravenously. The infectious diseases and general surgical services were consulted and a conserva- tive (non-operative) treatment plan initiated. The patient was discharged after 8 days with only the nephrostomy tube to straight drainage and prescriptions for Ciproﬂoxacin, Flagyl, and Pantoloc for 4 weeks. The per- cutaneous drain that was placed in her perinephric collec- tion was removed prior to her discharge as it had stopped draining. Follow-up consisted of serial imaging tests. A CT of the abdomen/pelvis at 2 weeks post discharge and a follow-up ultrasound 6 weeks post discharge demonstrated gradual improvement in the renal inﬂammatory mass but persistence of the ﬁstula. The patient was maintained on oral antibiotics to prevent further infections and to promote healing. At 9 weeks post initial discharge, the patient again pre- sented to the ER with ﬂank pain, fever, and nausea. A CT scan revealed tethering of the duodenum to the renal pelvis yet improvement in the appearance of the right kidney with minimal local ﬂuid, no locules of gas, and no obvious leak at the site of ﬁstula. The patient was admitted with a presump- tive diagnosis of pyelonephritis. Voided and nephrostomy urine cultures grew Enterococcus faecalis, while blood cul- tures were negative. The infection was treated with culture- directed therapy. She was maintained on Amoxicillin. * Maude Laberge maude.laberge@fsa.ulaval.ca 1 Department of Operations and Decision Systems, Université Laval, 2325, rue de la Terrasse, #2519, Quebec City, QC G1V0A6, Canada 2 Institute of Health, Policy, Management, and Evaluation, Toronto, ON, Canada 3 Division of Urology, Department of Surgery, University Health Network, Toronto, ON, Canada 4 Institute for Clinical Evaluative Sciences, Toronto, ON, Canada