An 81-year-old woman presented to the emergency department with a 2-week history of asthenia, anorexia and right lumbar pain.
Hemodynamically stable, with fever (38.5 degrees) for 3 days.
She had a history of heart failure associated with atrial fibrillation, with no history of urological diseases.
On physical examination, the patient developed severe pain on palpation of the right hemiabdomen, with no signs of peritoneal irritation, a palpable mass and positive renal Murphy on the right side.
The analyses showed leuocytosis (22,390 with left shift), normocytic normochromic anemia, with renal function within normal parameters, leucituria and microscopic hematuria.
A reno-vesical radiograph showed multiple radiopaque stones located in the right kidney.
Renal computed tomography (CT) with large intravenous contrast injection shows an enlarged right kidney with corticospinal disorganization of the spinal cord and the presence of multiple localized stones in the pelvis.
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With the diagnosis of pionephrosis and to stabilize the general deterioration we performed a percutaneous nephrostomy in the first time.
We observed abundant purulent fluid leaking through the nephrostomy that the culture of the same reveals polymicrobial flora.
She was started on broad-spectrum intravenous antibiotic therapy.
After four days and for presenting more suitable surgical conditions, we performed right nephrectomy by means of lumbotomy.
The description of the surgical specimen is:
Kidney (13x8.5x5 cm) was sent with a 10 cm long ureteral segment and presence of perirenal adipose tissue.
Dilatation of the pyelocaliceal tree and marked renal parenchyma is observed.
Purulent content is present inside the pyelic tree and stones are identified with a diameter greater than 4.5 cm. There are foci of suppuration with abcedification of the renal parenchyma and adipose tissue.
In the pelvis and adjacent cavities, white tissue with soft consistency measuring 6x5 cm away 10 cm from the ureteral surgical top is observed.
Histological examination showed adenocarcinoma with predominant tubular pattern areas and focal areas of tubulovillous pattern.
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The neoplasia presents characteristics of intestinal type adenocarcinoma, being possible to identify Goblet cells of the intestinal type that are characterized by the presence of intracytoplasmic apical mucus vacuums.
The nuclei in some areas are uniform and monotonous and in other areas are more aggressive, irregular, of different sizes and with frequent mitotic activity.
Tumor located in the subepithelial connective tissue.
In the foot-and-mouth disease coating, glandular metaplasia of the urothelial epithelium is identified.
Six months after surgery the patient died.
