Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2011  |  Volume : 22  |  Issue : 3  |  Page : 549--551

Nephrobronchial fistula complicating neglected nephrolithiasis and xanthogranulomatous pyelonephritis


Indu B Dubey, Ajay K Singh, Dharmendra Prasad, Bhupendra K Jain 
 Department of Surgery, University College of Medical Sciences (UCMS) and G.T.B. Hospital, Delhi, India

Correspondence Address:
Indu B Dubey
A-43, Street No. 2, Patel Vihar (Near Mukhiya Market), Karawal Nagar, Delhi 110094
India

Abstract

Nephrobronchial fistula is a rare complication seen in association with renal infections, trauma or stone disease. Xanthogranulomatous pyelonephritis (XGP) is an infectious disease with a potential for fistulization to lung, skin, colon and other organs. We present a case of nephrolithiasis complicated by obstruction leading to pyonephrosis and nephrobronchial fistula, treated successfully by nephrectomy and excision of fistulous tracts. Nephrobronchial fistula, although a rare complication of longstanding renal stone, should be considered when a patient presents with perirenal suppurative process. This clinical case illustrates the natural history of nephro-bronchial fistula and the relevance of early treatment of nephrolithiasis.



How to cite this article:
Dubey IB, Singh AK, Prasad D, Jain BK. Nephrobronchial fistula complicating neglected nephrolithiasis and xanthogranulomatous pyelonephritis.Saudi J Kidney Dis Transpl 2011;22:549-551


How to cite this URL:
Dubey IB, Singh AK, Prasad D, Jain BK. Nephrobronchial fistula complicating neglected nephrolithiasis and xanthogranulomatous pyelonephritis. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2022 Nov 27 ];22:549-551
Available from: https://www.sjkdt.org/text.asp?2011/22/3/549/80497


Full Text

 Introduction



Fistula formation between the kidney and thoracic cavity has been reported in literature from a number of causes, including infection, trauma, and stone disease. Infectious causes include xanthogranulomatous pyelonephritis (XGP), [1],[2] tuberculosis, [3] and renal abscesses. [4],[5] XGP is an uncommon but well recognized form of chronic inflammatory disease of kidney and is usually seen in patients with longstanding renal stones. [1] Reno-alimentary, nephrocutaneous or nephrobronchial fistula also may rarely be associated in XGP patients. [2],[6],[7],[8],[9],[10],[11]

 Case Report



A 15-year-old malnourished girl presented with a pus discharging sinus in left flank for four years. There was no fever, anorexia, weight loss, respiratory, urinary or bowel symptoms. On examination, there was a sinus draining purulent material in posterior aspect of left lumbar region with surrounding excoriated skin. Examination of chest and abdomen was otherwise unremarkable. Escherichia coli were grown in culture of urine. Urinary tests for fungus and tuberculosis were negative. Sinus edge biopsy revealed inflammatory granulation tissue without any evidence of tuberculosis or malignancy. Plain radiograph of kidney, ureter and bladder (KUB) region revealed a staghorn calculus on left side. Contrast study done through sinus in the lumbar region showed deformed and irregular renal calyces with a large calculus in the left kidney and multiple irregular tracts extending from left renal pelvis into mediastinum [Figure 1]. Renal scan was done which showed non-functioning left kidney with a differential function of 3% and glomerular filtration rate (GFR) of 1 mL/min. The other kidney was functioning normal.{Figure 1}

The kidney was explored through left subcostal incision. Gerota's fascia was thickened, edematous and had dense adhesions with surrounding structures. The kidney was enlarged with dilated pelvicalyceal system filled with staghorn stone and pus [Figure 2]. Multiple fistulous tracts were delineated after injecting methylene blue dye through sinus opening in the lumbar region. Further dissection of fistulous tracts revealed its extension into the posterior mediastinum through lumbocoastal triangle of diaphragm on the left side. Nephrectomy, excision of fistulous tracts and curettage were performed. Incision was closed after putting 30 F drain in the left renal space. Detection of methylene blue dye in endotracheal tube aspirate confirmed the extension of fistulous tract into the bronchial tree. Chest radiograph done in the postoperative period did not show any abnormality. The drain was removed on the fifth postoperative day. The patient made uneventful recovery and was discharged on the eighth postoperative day. Histopathological examination of the kidney showed XGP with nephrolithiasis and fistulous tracts lined with inflammatory granulation tissue. The patient became asymptomatic after surgery, and computed tomography done three months later showed no abnormality.{Figure 2}

 Discussion



Nephrobronchial fistula is an extremely rare complication of XGP, an atypical form of renal infection characterized by the tendency for invasive behavior, extension to adjacent structures, and organs, resulting in formation of fistulae. [12] Urinary tract obstruction, congenital urological anomalies, and recurrent urinary tract infections are mostly the accompanying disorders. [13] Infection by human immunodeficiency virus, association with diabetes mellitus and the presence of untreated renal stones are some of the predisposing factors. [14],[15],[16] There are two forms of XGP. The diffuse or global form (85%) is more common than the localized, focal or segmental form (15%). Diffuse XGP is staged as follows: Stage I, involvement is limited to kidney; Stage II, involvement extends to the renal pelvis or the perirenal fat within Gerota's fascia; and Stage III, involvement extends beyond Gerota's fascia into the retroperitoneum, other organs, or both. [17] The tendency of perirenal inflammation to spread superiorly was described by Evans and coworkers, [18] who noted that the lines of fusion of renal fascial planes tend to direct the exudates within the retroperitoneal compartment. The lumbocoastal triangle, a relatively weak area of diaphragm, can transmit infection into the thoracic cavity. [2] Although there are reports of successful management using conservative measures, [19] surgical drainage or nephrectomy remains the cornerstone of treatment. [20] However, a nephrectomy may be complicated by possible respiratory complications intra- and post-operatively. [21] Our case, Stage III XGP and coexisting nephrolithiasis which involved perirenal and pararenal tissues with consequent nephrocutaneous and nephrobronchial fistulization, was managed successfully by nephrectomy and excision of fistula. This case illustrates the natural history of nephrobronchial fistula and the relevance of early treatment of nephrolithiasis.

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