The Korea n J o urna l of Inte rnal Me dic ine Vol. 16 , No . 3 , Se pte mbe r, 200 1
INT RO DUCT IO N
Glome rulonephritis is a we ll known complication of bacterial endocarditis. The association of glome rulonephritis with visce ra l suppuration in the abse nce of e ndocarditis was initia lly recognized by Whitworth a nd associates1 ). Bea ufils and co- workers2 ) described 16 patie nts with visce ra l abscess and glome rulonephritis . Abscesses were most frequently located in the respiratory tract but have been reported at nume rous othe r s ites , including abdomen a nd ute rus . To our knowledge, there has bee n no reported adult case in the literature docume nting the occurre nce of severe glome rulonephritis in association with pyoge nic live r abscess . We describe he re a case of glome rulonephritis with acute rena l fa ilure in pyogenic liver abscess .
C a s e Re p o rt
A 66- yea r- old man was admitted to Ke imyung Unive rsity Hospita l beca use of decreased urine output a nd right uppe r quadrant pa in. Seve n years earlie r, he had a Whipple's operation for obstructive ja undice due to Ampulla of Vater ca ncer. At that time, the pathology report s howed a mode rately differe ntiated adenoca rci- noma a nd biops ies of the regiona l lymph nodes showed no evidence of metastas is . At that time, re na l function was norma l and the urine conta ined no prote ins or red cells. Two weeks before admission, the patient developed right uppe r quadra nt dull pa in, nausea, a norexia , mya lgia, chills a nd feve r. Four days prior to admiss ion, he noticed gross hematuria, ma rked decrease in urine output a nd ede ma in lower extre mities. On admiss ion, his body te mpe rature was 36.4℃ a nd blood pres s ure was 110/60 mmHg. Da ily urine output ra nged 800- 1200 mL.
Face was puffy. He did not have icterus . His conjunctivae was s light a ne mic a nd revea led severa l petechia l hemorrhages . Auscultation of the lung revea led bilate ra l bas ila r ra le s . No murmurs or frictions we re he a rd.
The live r was e nlarged a nd tender. There was no splenomegaly or ras h. There was marked costove rtebra l a ngle e nde rness . he re was mild pretibia l ede ma . Laboratory data on admiss ion s howed WBC 34,600/mm3, Address reprint reques ts to：Hy un Chul Kim, Dongsan
Kidney Institute, Keimy ung University Dongsan Hospital, 194 Dongsan Dong, Taegu, 700- 7 12 Korea.
A C a s e o f G lo m e r u lo n e p h r it is in As s o c ia t io n w it h P y o g e n ic Liv e r Ab s c e s s
M i J u n g Ka n g , M . D . , M in Ky u n g Ka n g , M . D . , S u n g B a e P a r k , M . D . , Hy u n C h u l Kim , M . D . a n d Kw a n Ky u P a r k , M . D . *
De p a rt m e nt s o f Int e rn a l M e d ic in e a n d Pat h o lo g y *, Do n g s a n K id n e y In s t it ut e , Ke im y u ng U n iv e rs ity S c h o o l o f M e d ic in e , T a e g u , Ko re a
G lo m e ru lo n e p h r it is a s s o c ia t e d w it h v is c e ra l a b s c e s s is b e in g in c re a s in g ly re c o g n iz e d . T h e a s s o c ia t io n o f g lo m e ru lo n e p h rit is w it h v is c e ra l s u p p u ra t io n in t h e a b s e n c e o f e n d o c a rd it is w a s f irs t d e s c rib e d b y W h it w o rt h a n d a s s o c ia t e s . A b s c e s s e s w e re m o s t f re q u e n t ly lo c a t e d in t h e re s p ira t o ry t ra c t b u t h a v e b e e n re p o rt e d a t n u m e ro u s o t h e r s it e s , in c lu d in g a p p e n d ix , u t e ru s , a o rt o - f e m o ra l b y p a s s g ra f t a n d c u t a n e o u s w o u n d . T h is re p o rt d o c u m e n t s t h e a p p a re n t ly ra re o c c u rre n c e o f g lo m e ru lo n e p h r it is w it h a c u t e re n a l f a ilu re in a s s o c ia t io n w it h p y o g e n ic liv e r a b s c e s s . T h e n e e d f o r a w a re n e s s o f g lo m e r u lo n e p h rit is a s a c a u s e o f a c u t e re n a l f a ilu re in p y o g e n ic liv e r a b s c e s s is h ig h lig h t e d .
Ke y Wo rds : Liver abscess ; Acute renal failure, Glom erulonephritis.
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A Cas e of Glom erulonephritis in As s ociation with Py ogenic Liver Abscess
hemoglobin 8.3 g/dL, platelet count 95,000/mm3, BUN 16.4 mmol/L, se rum creatinine 985.6 μmol/L, choleste rol 118 mg/dL, tota l bilirubin 3.4 mg/L, a lkaline phosphatase 270 IU/L, SGPT 18 IU/L, and serum albumin 2.0 g/dL and creatinine clearance 2.5 ml/min. Urinalysis showed specific gravity 1.020, protein 2+, a nd urinary sediment containg two granular casts, many red blood cells and 10 white blood cells/HPF. The 24- hour urinary protein excretion was 2.4 gm and FENa was 1.7%. C3 level was 0.67 g/L (normal ra nge: 0.8- 1.2 g/L) a nd C4 leve l was 0.46 g/L (normal ra nge: 0.2- 2.5 g/L). Cryoglobulin was absent. The tests for hepatitis B and C, antinuclear antibody and rheumatoid factor we re negative . Chest radiographs demonstrated bilate ral pe rihila r pulmona ry congestions . On admiss ion, he was afebrile. He had obvious pulmonary ede ma as well as peripheral edema. Immediate hemodialysis res ulted in a weight loss of 2 kg a nd respiratory improvement.
Ultrasonographic examination of liver showed ill ma rginated cystic mass in left lobe. Computed tomography (CT) of the abdomen demonstrated 7×5cm s ized multiple septated lower density les ions in medial segment of left lobe of the liver (Figure 1). Numerous blood cultures we re negative . Initia lly the patie nt was treated with diuretics , albumin infusions and antibiotics (sulbactam/cefope razone a nd aztreona m). On the 15th day, percutaneous needle biopsy of the kidney was performed. Light microscopy s howed 17 glomeruli with two global scleros is . The glome ruli showed endo- and extracapilla ry prolife ration (Figure 2), with cellula r crescents involving 25% of the glome ruli. The interstitium showed diffuse edema and no tubular necrosis. Immunofluoresce nt examination s howed a diffuse gra nular sta ining with a nti- IgG and anti- C3
a long the capillary wa ll, and no sta ining with anti- IgM or a nti- IgA (Figure 3). Needle aspiration of the liver was performed on the 19th hospital day, with the dra inage of gree nis h pus mate ria l. Culture of the live r aspirates late r grew Pseudomonas aeruginosa. Ticarcillin was give n.
The patie nt improved s ubsta ntia lly. The leve ls of BUN a nd serum creatinine declined progress ively a nd stabilized at 5.7 mmol/L a nd 176 µ mol/L, respective ly, by the 25th hospital day. One month afte r admiss ion, the laboratory findings were : BUN 5.5 mmol/L, serum creatinine 176 µ mol/L, hemoglobin 8.1g/dL. WBC 5,430/mm3 a nd platelet count 208,000/mm3. The 24- hour urina ry protein excretion was 4.4 g/day. Follow- up CT s howed almost complete resolution of previous abscess in the liver. He was discha rged on the 40th hospita l day with the se rum creatinine leve l of 167 µ mol/L.
F ig ure 1. Abdomina l CT s howing 7×5 cm s ized multiple sepa rated lowe r de ns ity les ion in media l segme nt of left hepatic lobe .
F ig ure 2 . Re na l biopsy s howing a crescent formation a nd a glome rulus with a ce llua r prolife ration (H & E sta in, ×200)
F ig ure 3 . IF s hows a diffuse gra nula r sta ining with a nti- IgG a nd a nti- C3 a long the capilla ry wa ll
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M.J. Kang, M.K. Kang, S .B. Park, H.C. Kim, K.K. Park
Dis c u s s io n
The present case report de monstrates the association between pyogenic live r abscess and glome rulonephritis with acute re na l fa ilure. The occurre nce of glomerula r les ions in s uch cas e may be ove rlooked beca use re na l biopsy is rare ly pe rformed in patie nts with life thre ate ning pyoge nic infections , s ince tubula r necros is is usually cons idered the most cause of acute re nal failure . The ca use of acute re na l fa ilure in this patient favored a diagnosis of glomerulonephritis over tubula r necrosis in view of the clinica l finding of ma croscopic he maturia at the onset a nd gradua l deve lopme nt of oliguria and s ubsequent renal biopsy confirmed this.
Occurrence of glomerulonephritis during bacterial infection is we ll docume nted in three circumsta nces : s ubacute bacte ria l endocarditis2 - 5 ), Staph. aureus infection to the ventriculoatria l shunt6 ) and Staph. a ure us septicemia with acute endoca rditis7 ). The association of glome rulonephritis with visce ral abscess in the absence of e ndoca rditis was initially recognized by Whitworth a nd associates1 ) and by Bea ufils and co- worke rs2 ). In Beaufils's se ries2 ), among 16 cases of viscera l abscesses, the respiratory tract was the most frequent localization in eight cases. The remaining cases were due to appendiceal abscess in 2, septic abortion in 2, subphrenic abscess, acute osteomyelitis, aorto- femoral bypass and cutaneous wound.
There has been no reported case of glomerulonephritis in association with pyoge nic live r abscess in a large series of viscera l infection- associated glome rulonephritis a ccording to a compre he ns ive review of lite rature by Co le ma n et a l8 ). The re ha s be e n o nly one re port of solitary pyoge nic live r abscess with associated glome rulonephritis in a neonate9 ). Thus , our case may be the first report documenting the occurre nce of glome rulonephritis associated with the pyogenic liver abscess in a adult. A va riety of bacte ria have bee n implicated. Pseudomonas aeruginosa was the respons ible orga nism in our case and 2 out of 8 cases of culture- proven visceral infection in Beaufils and co- worke r's s e rie s2 ). An immunopathoge ne s is wa s s ugge sted by the freque nt prese nce of hypocomple me nte mia , cry- oglobuline mia a nd circulating immune complexes in a ll forms of infection- as s ociate d glome rulonephritis1 0 ). In our patie nt, depres sed se rum comple me nt a nd the prese nce of diffuse granula r depos its of C3 a nd IgG by
immunofluorescent microscopy a re highly s uggestive of an immunologic process. The glomerular lesion associated with visce ra l abscess is us ually a proliferative glome rulo- nephritis with va rying degree of crescents .
Acute rena l fa ilure was the principal manifestation of renal involvement in Beaufils et al2 ), but proteinuria and/or hematuria also occurred in othe r series1 1- 12 ). Our patient had acute re nal fa ilure seve re e nough to require hemodialys is , a nd s ubseque nt kidney biopsy s howed e ndo- and extracapillary proliferation.
Of crucia l importa nce is the rea lization that clinica l a nd morphologica l recove ry from infection associated glome rulonephritis is possible if the infection is quickly a nd complete ly e radicated10 ). Striking clinica l improvement a nd rapid regress ion of re nal failure was noted in our case with the resolution of the abscess in the live r by follow- up CT study. Pyogenic live r abscess may be respons ible for a reve rs ible glomerulonephritis with acute re na l failure through an immunologic process .
R E F E R E NC E S
1. Whitworth JA, Morel- Maroger L, Mignon F, Richet G. The significance of extracapillary proliferation : clinicopathological revie w of 60 patients. Nephron 16:1- 19, 1976
2. Bea ufils M, Gibe rt C, morel- Me roge r L, Sraer J D, Ka nfer A, Meyrier A, Kourils ky O, Vachon F, Richet G.
Glomerulonephritis in se vere bacterial infections with and without endocarditis. Adv Nephrol 7:2 17-234, 1977 3. Be ll ET. Glomerular lesions associated with endocarditis.
Am J Pathol 8:639-, 1932
4. Gutman RA, Stricke r GE, Gillila nd BC, Cutler RE. The immune complex glomerulonephritis of bacterial endocarditis.
Medicine 5 1:1-25, 1972
5. Kes lin MH, Mess ne r RP, Williams RC. Glomerulonephritis with s ubacte bacterial endocarditis, Immunofluorescent studies, Arch Int Med 132:578- 8 1, 1973
6. Black JA, Cha llacomve DN, Ocke nde n BG. Nephrotic syndrome ass ociated with bacteremia after shunt operation for hy drocephalus. Lancet 2:92 1-4, 1965
7. Tu WH, Shea rn MA, Lee J C. Acute diffus e glomerulonephritis in acute s taphylococcal endocarditis.
Ann Intern Med 7 1:335- 34 1, 1969
8. Colema n M, Burnett J , Ba rratt J , Dupont P.
Glomerulonephritis associated with chronic bacterial infection of a dacron arterial prosthesis. Clin Nephrol 20:3 15- 320, 1983
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A Cas e of Glom erulonephritis in As s ociation with Py ogenic Liver Abscess
9. Beaufils M, morel- Margoge r l, Srae r J D, Ka nfer A, Kourils ky O, Richet G. Acute renal failure of glomerular origin during visceral abscess es. N Engl J Med 295:185- 189, 1976
10. De Franco PE, Shook LA, Goebe l J , Lee B. Is olitary hepatic abscess with associated glomerulonephritis. J Perinatol 20:384- 386, 2000
11. Forrest JW, Mills J LR, Buxton TB, Moore WC, Hudson J B, Ozawa T. Immune complex glomerulonephritis associated with Klebsiella pneumonia infection. Clin Nephrol 7:76- 80, 1977
12. Kaehny WD, Schwa rz MI, McIntos h RM, Gugge nhe im SJ , Sta nford R, Ozawa T. Pos t-pneumococcal immune glomerulonephritis and alveolitis. Clin Res 24:403A, 1976
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