Difference between revisions of "Xanthogranulomatous pyelonephritis"

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Xanthogranulomatous pyelonephritis (view source)

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#redirect [[Kidney_tumours#Xanthogranulomatous_pyelonephritis]]
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = Xanthogranulomatous_pyelonephritis_cd68.jpg
| Width      =
| Caption    = Xanthogranulomatous pyelonephritis. CD68 immunostain.
| Synonyms  =
| Micro      = abundant (foamy) macrophages (associated with the collecting system - medulla, not cortex), +/-giant cells, +/-cholesterol clefts, +/-interstitial lymphocytes and plasma cells, +/-interstitial fibrosis, +/-calcifications
| Subtypes  =
| LMDDx      = [[malakoplakia]], RCC - especially [[PRCC]], granulomatous disease, [[chronic pyelonephritis]], interstitial nephritis, occasionally [[renal cell carcinoma]]
| Stains    = [[PAS-D]] -ve
| IHC        = CD68 +ve, CD10 -ve, [[pankeratin]] -ve
| EM        =
| Molecular  =
| IF        =
| Gross      =
| Grossing  =
| Site      = [[kidney]] - see ''[[kidney tumours]]''
| Assdx      = [[diabetes mellitus]], history of UTI, [[nephrolithiasis]], GU obstruction (various causes)
| Syndromes  =
| Clinicalhx =
| Signs      =
| Symptoms  =
| Prevalence = uncommon
| Bloodwork  =
| Rads      = dilated upper GU system
| Endoscopy  =
| Prognosis  =
| Other      =
| ClinDDx    = [[renal cell carcinoma]], [[pyelonephritis]]
| Tx        = antibiotics, occasionally nephrectomy
}}
'''Xanthogranulomatous pyelonephritis''', abbreviated '''XGP''', is an inflammatory process of the [[kidney]] that can mimic [[renal cell carcinoma]].


==General==
*May mimic [[renal cell carcinoma]] - especially radiologically.
*Usually lower pole.{{fact}}
*Associated with:
**[[Diabetes mellitus]].
**History of [[urinary tract infection]].<ref name=pmid17987581>{{cite journal |author=Afgan F, Mumtaz S, Ather MH |title=Preoperative diagnosis of xanthogranulomatous pyelonephritis |journal=Urol J |volume=4 |issue=3 |pages=169–73 |year=2007 |pmid=17987581 |doi= |url=}}</ref>
**[[Nephrolithiasis]].
**GU obstruction.<ref name=pmid17098659>{{cite journal |author=Al-Ghazo MA, Ghalayini IF, Matalka II, Al-Kaisi NS, Khader YS |title=Xanthogranulomatous pyelonephritis: Analysis of 18 cases |journal=Asian J Surg |volume=29 |issue=4 |pages=257–61 |year=2006 |month=October |pmid=17098659 |doi= |url=}}</ref>
*Occasionally an indication for nephrectomy.<ref name=pmid17987581/><ref name=pmid17098659/>
*Most common organism (in the context of nephrectomy specimens) - ''Proteus mirabilis''.<ref name=pmid17098659/>
==Microscopic==
Features:
*Abundant (foamy) macrophages.
**Associated with the collecting system - medulla, not cortex.
*+/-Giant cells.
*+/-Interstitial lymphocytes and plasma cells.
*+/-Interstitial fibrosis.
*+/-Cholesterol clefts (common).
*+/-Calcifications - dystrophic.
DDx:
*[[Malakoplakia]].
**Basophilic inclusions -- inside or outside of macrophages - often size of RBC or larger ([[Michaelis-Gutmann bodies]]).
*[[Renal cell carcinoma]] - especially [[papillary RCC]] (as this has foamy macrophages).
*[[Granulomatous disease]].
*[[Chronic pyelonephritis]].
*[[Interstitial nephritis]].
*[[Renal cell carcinoma]] - foamy macrophages may be abundant.<ref name=pmid8378177>{{Cite journal  | last1 = Iskandar | first1 = SS. | last2 = Prahlow | first2 = JA. | last3 = White | first3 = WL. | title = Lipid-laden foamy macrophages in renal cell carcinoma. Potential frozen section diagnostic pitfall. | journal = Pathol Res Pract | volume = 189 | issue = 5 | pages = 549-52 | month = Jun | year = 1993 | doi = 10.1016/S0344-0338(11)80364-X | PMID = 8378177 }}</ref>
===Images===
<gallery>
Image:Xanthogranulomatous_pyelonephritis_cd68.jpg | Xanthogranulomatous pyelonephritis - CD68 stain. (WC/Nephron)
</gallery>
www:
*[http://www.archivesofpathology.org/na101/home/literatum/publisher/pinnacle/journals/content/arpa/2011/15432165-135.5/2009-0769-rsr.1/production/images/large/i1543-2165-135-5-671-f01.jpeg Several images of XGP (archivesofpathology.org)].<ref name=pmid21526966>{{Cite journal  | last1 = Li | first1 = L. | last2 = Parwani | first2 = AV. | title = Xanthogranulomatous pyelonephritis. | journal = Arch Pathol Lab Med | volume = 135 | issue = 5 | pages = 671-4 | month = May | year = 2011 | doi = 10.1043/2009-0769-RSR.1 | PMID = 21526966 }}</ref>
==Stains==
*[[PAS-D]] -ve.
**Done to look for malakoplakia.
==IHC==
*CD68 +ve.
*RCC markers (CD10, RCC) all negative.
==Sign out==
<pre>
RIGHT KIDNEY, NEPHRECTOMY:
- XANTHOGRANULOMATOUS PYELONEPHRITIS.
- CHRONIC INTERSTITIAL NEPHRITIS.
- INCREASED NUMBERS OF TOTALLY SCLEROSED GLOMERULI AND GLOMERULI WITH FOCAL
  SCLEROSIS.
- MARKED INTERSTITIAL FIBROSIS.
- NEGATIVE FOR MALIGNANCY.
COMMENT:
Immunostaining demonstrates abundant CD68 positive cells (macrophages).  A CD10 immunostain
is non-concerning (it highlights glomeruli). A pankeratin immunostain is non-concerning
(it highlights benign renal tubules).
</pre>
===Compatible XGP===
<pre>
"KIDNEY" LESION, LEFT, BIOPSY:
- FIBROMUSCULAR TISSUE WITH A MIXED INFLAMMATORY INFILTRATE.
- CELLULAR DEBRIS WITH SURROUNDING LOOSELY AGGREGATED HISTIOCYTES.
- NO RENAL PARENCHYMA IDENTIFIED.
- NEGATIVE FOR MALIGNANCY.
COMMENT:
A SMA immunostain highlights the muscle component, and a CD68 immunostain marks
abundant histiocytes. No epithelial component is identified with a pankeratin
immunostain.
</pre>
===Micro===
The sections show degenerative renal parenchyma with surrounding histiocytes, other inflammatory cells, fibrosis and cholesterol clefts.
==See also==
*[[Kidney tumours]].
*[[Acute pyelonephritis]].
*[[Xanthogranulomatous cystitis]].
==References==
{{Reflist|2}}
[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Kidney tumours]]
Michael
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