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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">Urinary infections are common during pregnancy&#44; affecting 10-15&#37; of women&#46; In 1-2&#46;5&#37; of pregnancies there are complications due to acute pyelonephritis<span class="elsevierStyleSup">1</span> and the infection is recurrent in up to 10&#37; of women&#46; The development of a kidney abscess secondary to acute pyelonephritis is uncommon during pregnancy&#46; This can affect patients with urinary tract alterations and diagnosis of the condition requires a high index of suspicion and confirmation using ultrasound&#46;<span class="elsevierStyleSup">2-5</span> The most common causal agents are enterobacteria&#46; The infection most commonly affects the right kidney &#40;90&#37;&#41;&#44; it is usually unilateral and associated with high morbidity&#44; which is why early diagnosis and treatment are necessary&#46;<span class="elsevierStyleSup">1&#44;2-4</span></p><p class="elsevierStylePara">This is the case of a 23-year-old woman with a history of repeated urinary tract infections since the age of 16&#46; In 2005 she miscarried at 12 weeks and this coincided with a urinary infection caused by Escherichia coli&#46; In November 2006 when she was 12 weeks pregnant&#44; the following results were obtained from a urine test&#58; pH 7&#46;5&#44; nitrites &#40;&#43;&#41;&#44; leukocytes &#40;&#43;&#43;&#41;&#46; Sediment&#58; leukocytes 20-40 per field and abundant bacteria&#46; No treatment was prescribed&#46; On 4 January 2007 when she was 20 weeks pregnant&#44; she had a fever of 39&#186; C and pain in the right renal fossa&#46; The biochemistry showed&#58; leukocytes 27&#44;800&#47;mm<span class="elsevierStyleSup">3</span> &#40;85&#37; neutrophils&#41;&#44; Hb 8&#46;7g&#47;dl&#44; platelets 288&#44;000&#47;mm<span class="elsevierStyleSup">3</span> and GSV 16-39mm&#47;h&#46; Other data&#58; Na 138mmol&#47;l&#44; K 4&#46;8mmol&#47;l&#44; Cl 96mmol&#47;l&#44; glucose 66mg&#47;dl&#44; urea 48mg&#47;dl&#44; creatinine 0&#46;7mg&#47;dl&#44; uric acid 3&#46;4mg&#47;dl and CRP 31mg&#47;dl&#46; Urine&#58; blood 25&#47;ml&#44; nitrites &#40;&#43;&#41;&#44; leukocytes 100&#47;ml&#46; Sediment&#58; leukocytes 31-50 per field&#44; isolated red blood cells and abundant bacteria&#46; Urine culture&#58; Escherichia coli&#46; She received 1g&#47;12 hours of intravenous cefotaxim treatment for four days&#46; The fever disappeared after 48 hours and there were improvements in her clinical condition and test results&#46; On 18 January 2007&#44; in the 22nd week of pregnancy&#44; she was admitted into hospital again with the same symptoms&#46; The biochemistry showed&#58; leukocytes 36&#44;800&#47;mm<span class="elsevierStyleSup">3</span> &#40;91&#37; neutrophils&#41;&#44; Hb 8&#46;4g&#47;dl&#44; platelets 357&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#46; Urine&#58; leukocytes &#40;&#43;&#43;&#43;&#41;&#44; proteinuria &#40;&#43;&#43;&#41;&#44; urea 55mg&#47;dl&#44; creatinine 1&#46;2mg&#47;dl&#44; total proteins 5&#46;1g&#47;dl and CRP 69mg&#47;dl&#46; The ultrasound showed&#58; the right kidney increased in size &#40;14cm larger in diameter&#41;&#44; with a reduction in the corticomedullary differentiation and a hypoecogenic image of 8mm at cortical level in the upper pole&#44; with echogenic content that was suggestive of a corticomedullary abscess&#44; moderate dilatation of the calyx&#44; pelvis and proximal ureter &#40;figure 1&#41;&#46; The major axis of the left kidney measured 12&#46;7cm&#44; echogenicity was normal and there was mild pyelocalceal dilatation&#46; The patient was first administered treatment with amoxicillin clavulanate 500mg&#47;8 hours&#44; and then 850&#47;125mg&#47;8 hours&#59; after 48 hours her fever subsided and her symptoms improved&#46; Nine days after the first ultrasound&#44; a second one was carried out which continued to show the image of the abscess in the right kidney&#46; On 8 February 2007&#44; when she was 24 weeks pregnant a MRI scan showed bilateral pyeloureteral dilatation that was greater on the right side&#44; with blunting of the calyceal fornices and a renal pelvis measuring 2&#46;8cm&#46; The right kidney was enlarged with deteriorated corticomedullary differentiation&#46; There was a hyperintense image 8-10mm in diameter in the upper pole around the corticomedullary area&#44; which seemed to be a parenchymatous abscess &#40;figure 2&#41;&#46; Treatment using amoxillin clavulanate 875&#47;125mg&#47;8 hours was administered for three weeks&#46; The clinical progress made by the patient was favourable and leukocyte levels were normalised &#40;figure 3&#41;&#46; After two weeks&#44; a new MRI scan showed a microabscess which was 15mm in diameter and a renal pelvis of 3cm&#46; In a new ultrasound scan carried out three weeks later&#44; the lesion had decreased in size&#46; Antibiotic therapy continued &#40;oral amoxicillin clavulanate&#41; for two more weeks until the five week course of treatment was completed&#46; Regular ultrasound scans detected the ongoing presence of the abscess which is why patient treatment was switched to phosphomycin 500mg&#47;8 hours for three weeks &#40;from 7 to 28 March&#41;&#46; The patient continued to go for check ups at the GP&#191;s and a new MRI scan showed the presence of lesions&#46; The patient was then admitted into hospital once again&#46; On admission the following results were obtained&#58; leukocytes 15&#44;700 &#40;neutrophils 74&#46;5&#37;&#41; and urine sediment with 20-30 leukocytes per field&#46; She was then administered cefotaxim 2g&#47;8 hours for five weeks&#46; On 4 May when she was 38 weeks pregnant&#44; labour was induced&#44; resulting in a live birth &#40;weight 2&#46;94kg&#41; without complications&#46; A new control MRI scan was carried out a week after delivery which showed the renal abscess in the right kidney and its content&#46; The patient was referred to the Urology Department so vesicoureteral reflux tests could be carried out and in order to check that the patient had recovered&#46; The tests indicated that the abscess had disappeared&#46;</p><p class="elsevierStylePara">Pregnant women have a higher risk of suffering from urinary infections&#44;<span class="elsevierStyleSup">1</span> however&#44; the development of acute pyelonephritis with a renal abscess is an extremely rare complication<span class="elsevierStyleSup">2-4</span> that is challenging in terms of treatment&#46;<br></br>The diagnosis of a kidney infection is fundamentally based on symptoms like fever&#44; shivering and side pain&#44;<span class="elsevierStyleSup">6&#44;7</span> by means of imaging techniques&#46; The technique of choice during pregnancy is the ultrasound&#46; Segmentary&#160; pyelonephritis &#40;lobar nephronia&#41; appears in the ultrasound as a solid oval-shaped mass with edges that are not clearly defined&#44; whereas an abscess appears as clearly identifiable mass that is similar to a cyst&#46; The presence of internal echoes or layers of cellular debris within a well defined mass with an irregular internal wall suggests an abscess&#46;<span class="elsevierStyleSup">6&#44;7</span> For patients who are not pregnant a CT scan is the method of choice for detecting acute pyelonephritis and&#47;or a renal abscess&#46;<span class="elsevierStyleSup">8-10</span>A renal abscess appears in a CT scan as a mass that does not contrast&#44; with a swollen&#44; irregular wall&#44; which could present liquid and cellular detritus inside&#44; as well as internal septa&#46; Since the MRI scan avoids the use of ionising radiation&#44; it is an imaging technique which is used extensively in obstetrics&#46;<span class="elsevierStyleSup">11-13</span> Until now only one case involving a pregnant patient with a renal cortical abscess detected using MRI had been published&#46;<span class="elsevierStyleSup">2</span> In MRI scans the renal abscess has the appearance of a rounded lesion with a swollen wall&#44; which has a low signal intensity that is not homogeneous on the T1 weighted image and increasing signal intensity on the T2 weighted image&#46; We were also able to observe the presence of liquid with detritus&#46; Furthermore&#44; the MRI can accurately show the level of obstruction in the urinary tract or any other anomalies like vesicoureteral reflux that may be present during the pregnancy&#46; Although gadolinium is contraindicated during the first trimester of pregnancy&#44; it can be used during the second and third trimesters in order to investigate foetal and placental anomalies that are not clearly defined in an ultrasound scan&#46;<span class="elsevierStyleSup">11&#44;14</span> Acortical renal abscess is associated with a mortality rate of 1&#46;5-15&#37;&#46; Therefore&#44; treatment should be aggressive and based on combining intensive antibiotic therapy with percutaneous drainage or surgery&#46;<span class="elsevierStyleSup">3</span> With ultrasound and MRI scans being used more frequently&#44; the availability of more powerful antibiotics and better support measures are in place&#44; in many cases medical treatment is a viable alternative to surgery&#46;<span class="elsevierStyleSup">3&#44;7&#44;9</span> Prolonged antibiotic treatment has a more beneficial effect on reducing morbidity and preserving renal mass and function&#46;<span class="elsevierStyleSup">7&#44;9</span> Our patient presented the three key symptoms&#58; fever&#44; side pain and pyuria&#44; which is characteristic of an upper urinary tract infection&#46; In this case&#44; apart from urinary stasis and hydronephrosis caused by the pregnancy&#44;<span class="elsevierStyleSup">5</span> there were other factors that favoured the condition like previous urinary tract infections and vesicoureteral reflux&#46; The ultrasound and MRI scan made an early diagnosis possible&#44; showing the presence of a renal corticomedullary abscess and dilatation of the upper urinary tract&#46; Close monitoring of lesions using regular ultrasound and MRI scans and ongoing&#44; rotated antibiotic treatment made it possible to successfully bring the pregnancy to term without having to resort to surgical drainage&#46;</p><p class="elsevierStylePara">In summary&#44; we have described an exceptional case of a women who was 24 weeks pregnant who presented acute pyelonephritis caused by Escherichia coli&#44; which was further complicated by a corticomedullary renal abscess&#46; The diagnosis was confirmed using ultrasound and MRI scans&#46; The ongoing antibiotic treatment made it possible to keep the pregnancy and bring it to term in the 38th week&#44; resulting in a normal live birth&#46; The patient also made a full recovery without having to resort to percutaneous drainage&#46; This case highlights that MRI scans can be useful for detecting specific urological problems like a complicated case of pyelonephritis with a renal abscess&#44; hydronephrosis and vesicoureteral reflux&#46; Given the favourable prognosis for mother and foetus&#44; this case also shows that conservative medical treatment is a viable alternative to surgery&#46; </p><p class="elsevierStylePara"><a href="grande&#47;42718078&#95;f1&#95;pag492&#46;jpg" class="elsevierStyleCrossRefs"><img src="42718078_f1_pag492.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;42718078&#95;f2&#95;pag493&#46;jpg" class="elsevierStyleCrossRefs"><img src="42718078_f2_pag493.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p><p class="elsevierStylePara"><a href="grande&#47;42718078&#95;f3&#95;pag493&#46;jpg" class="elsevierStyleCrossRefs"><img src="42718078_f3_pag493.jpg"></img></a></p><p class="elsevierStylePara">Figure 3&#46; </p>"
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Pregnant patient with acute pyelonephritis and renal corticomedullary abcess: ultrasound and MRI imaging
Pielonefritis aguda con absceso corticomedular renal en una mujer embarazada: imagen ecográfica y por resonancia magnética
Ramón Pecesa, A.L.. Beníteza, R.. Sánchez Villanuevaa, C.. Pecesb, E.. Cuestac
a Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Madrid, España,
b Área de Tecnologías de la Información, SESCAM, Toledo, Toledo, España,
c Servicio de Radiología, Hospital Universitario La Paz, Madrid, Madrid, España,
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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">Urinary infections are common during pregnancy&#44; affecting 10-15&#37; of women&#46; In 1-2&#46;5&#37; of pregnancies there are complications due to acute pyelonephritis<span class="elsevierStyleSup">1</span> and the infection is recurrent in up to 10&#37; of women&#46; The development of a kidney abscess secondary to acute pyelonephritis is uncommon during pregnancy&#46; This can affect patients with urinary tract alterations and diagnosis of the condition requires a high index of suspicion and confirmation using ultrasound&#46;<span class="elsevierStyleSup">2-5</span> The most common causal agents are enterobacteria&#46; The infection most commonly affects the right kidney &#40;90&#37;&#41;&#44; it is usually unilateral and associated with high morbidity&#44; which is why early diagnosis and treatment are necessary&#46;<span class="elsevierStyleSup">1&#44;2-4</span></p><p class="elsevierStylePara">This is the case of a 23-year-old woman with a history of repeated urinary tract infections since the age of 16&#46; In 2005 she miscarried at 12 weeks and this coincided with a urinary infection caused by Escherichia coli&#46; In November 2006 when she was 12 weeks pregnant&#44; the following results were obtained from a urine test&#58; pH 7&#46;5&#44; nitrites &#40;&#43;&#41;&#44; leukocytes &#40;&#43;&#43;&#41;&#46; Sediment&#58; leukocytes 20-40 per field and abundant bacteria&#46; No treatment was prescribed&#46; On 4 January 2007 when she was 20 weeks pregnant&#44; she had a fever of 39&#186; C and pain in the right renal fossa&#46; The biochemistry showed&#58; leukocytes 27&#44;800&#47;mm<span class="elsevierStyleSup">3</span> &#40;85&#37; neutrophils&#41;&#44; Hb 8&#46;7g&#47;dl&#44; platelets 288&#44;000&#47;mm<span class="elsevierStyleSup">3</span> and GSV 16-39mm&#47;h&#46; Other data&#58; Na 138mmol&#47;l&#44; K 4&#46;8mmol&#47;l&#44; Cl 96mmol&#47;l&#44; glucose 66mg&#47;dl&#44; urea 48mg&#47;dl&#44; creatinine 0&#46;7mg&#47;dl&#44; uric acid 3&#46;4mg&#47;dl and CRP 31mg&#47;dl&#46; Urine&#58; blood 25&#47;ml&#44; nitrites &#40;&#43;&#41;&#44; leukocytes 100&#47;ml&#46; Sediment&#58; leukocytes 31-50 per field&#44; isolated red blood cells and abundant bacteria&#46; Urine culture&#58; Escherichia coli&#46; She received 1g&#47;12 hours of intravenous cefotaxim treatment for four days&#46; The fever disappeared after 48 hours and there were improvements in her clinical condition and test results&#46; On 18 January 2007&#44; in the 22nd week of pregnancy&#44; she was admitted into hospital again with the same symptoms&#46; The biochemistry showed&#58; leukocytes 36&#44;800&#47;mm<span class="elsevierStyleSup">3</span> &#40;91&#37; neutrophils&#41;&#44; Hb 8&#46;4g&#47;dl&#44; platelets 357&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#46; Urine&#58; leukocytes &#40;&#43;&#43;&#43;&#41;&#44; proteinuria &#40;&#43;&#43;&#41;&#44; urea 55mg&#47;dl&#44; creatinine 1&#46;2mg&#47;dl&#44; total proteins 5&#46;1g&#47;dl and CRP 69mg&#47;dl&#46; The ultrasound showed&#58; the right kidney increased in size &#40;14cm larger in diameter&#41;&#44; with a reduction in the corticomedullary differentiation and a hypoecogenic image of 8mm at cortical level in the upper pole&#44; with echogenic content that was suggestive of a corticomedullary abscess&#44; moderate dilatation of the calyx&#44; pelvis and proximal ureter &#40;figure 1&#41;&#46; The major axis of the left kidney measured 12&#46;7cm&#44; echogenicity was normal and there was mild pyelocalceal dilatation&#46; The patient was first administered treatment with amoxicillin clavulanate 500mg&#47;8 hours&#44; and then 850&#47;125mg&#47;8 hours&#59; after 48 hours her fever subsided and her symptoms improved&#46; Nine days after the first ultrasound&#44; a second one was carried out which continued to show the image of the abscess in the right kidney&#46; On 8 February 2007&#44; when she was 24 weeks pregnant a MRI scan showed bilateral pyeloureteral dilatation that was greater on the right side&#44; with blunting of the calyceal fornices and a renal pelvis measuring 2&#46;8cm&#46; The right kidney was enlarged with deteriorated corticomedullary differentiation&#46; There was a hyperintense image 8-10mm in diameter in the upper pole around the corticomedullary area&#44; which seemed to be a parenchymatous abscess &#40;figure 2&#41;&#46; Treatment using amoxillin clavulanate 875&#47;125mg&#47;8 hours was administered for three weeks&#46; The clinical progress made by the patient was favourable and leukocyte levels were normalised &#40;figure 3&#41;&#46; After two weeks&#44; a new MRI scan showed a microabscess which was 15mm in diameter and a renal pelvis of 3cm&#46; In a new ultrasound scan carried out three weeks later&#44; the lesion had decreased in size&#46; Antibiotic therapy continued &#40;oral amoxicillin clavulanate&#41; for two more weeks until the five week course of treatment was completed&#46; Regular ultrasound scans detected the ongoing presence of the abscess which is why patient treatment was switched to phosphomycin 500mg&#47;8 hours for three weeks &#40;from 7 to 28 March&#41;&#46; The patient continued to go for check ups at the GP&#191;s and a new MRI scan showed the presence of lesions&#46; The patient was then admitted into hospital once again&#46; On admission the following results were obtained&#58; leukocytes 15&#44;700 &#40;neutrophils 74&#46;5&#37;&#41; and urine sediment with 20-30 leukocytes per field&#46; She was then administered cefotaxim 2g&#47;8 hours for five weeks&#46; On 4 May when she was 38 weeks pregnant&#44; labour was induced&#44; resulting in a live birth &#40;weight 2&#46;94kg&#41; without complications&#46; A new control MRI scan was carried out a week after delivery which showed the renal abscess in the right kidney and its content&#46; The patient was referred to the Urology Department so vesicoureteral reflux tests could be carried out and in order to check that the patient had recovered&#46; The tests indicated that the abscess had disappeared&#46;</p><p class="elsevierStylePara">Pregnant women have a higher risk of suffering from urinary infections&#44;<span class="elsevierStyleSup">1</span> however&#44; the development of acute pyelonephritis with a renal abscess is an extremely rare complication<span class="elsevierStyleSup">2-4</span> that is challenging in terms of treatment&#46;<br></br>The diagnosis of a kidney infection is fundamentally based on symptoms like fever&#44; shivering and side pain&#44;<span class="elsevierStyleSup">6&#44;7</span> by means of imaging techniques&#46; The technique of choice during pregnancy is the ultrasound&#46; Segmentary&#160; pyelonephritis &#40;lobar nephronia&#41; appears in the ultrasound as a solid oval-shaped mass with edges that are not clearly defined&#44; whereas an abscess appears as clearly identifiable mass that is similar to a cyst&#46; The presence of internal echoes or layers of cellular debris within a well defined mass with an irregular internal wall suggests an abscess&#46;<span class="elsevierStyleSup">6&#44;7</span> For patients who are not pregnant a CT scan is the method of choice for detecting acute pyelonephritis and&#47;or a renal abscess&#46;<span class="elsevierStyleSup">8-10</span>A renal abscess appears in a CT scan as a mass that does not contrast&#44; with a swollen&#44; irregular wall&#44; which could present liquid and cellular detritus inside&#44; as well as internal septa&#46; Since the MRI scan avoids the use of ionising radiation&#44; it is an imaging technique which is used extensively in obstetrics&#46;<span class="elsevierStyleSup">11-13</span> Until now only one case involving a pregnant patient with a renal cortical abscess detected using MRI had been published&#46;<span class="elsevierStyleSup">2</span> In MRI scans the renal abscess has the appearance of a rounded lesion with a swollen wall&#44; which has a low signal intensity that is not homogeneous on the T1 weighted image and increasing signal intensity on the T2 weighted image&#46; We were also able to observe the presence of liquid with detritus&#46; Furthermore&#44; the MRI can accurately show the level of obstruction in the urinary tract or any other anomalies like vesicoureteral reflux that may be present during the pregnancy&#46; Although gadolinium is contraindicated during the first trimester of pregnancy&#44; it can be used during the second and third trimesters in order to investigate foetal and placental anomalies that are not clearly defined in an ultrasound scan&#46;<span class="elsevierStyleSup">11&#44;14</span> Acortical renal abscess is associated with a mortality rate of 1&#46;5-15&#37;&#46; Therefore&#44; treatment should be aggressive and based on combining intensive antibiotic therapy with percutaneous drainage or surgery&#46;<span class="elsevierStyleSup">3</span> With ultrasound and MRI scans being used more frequently&#44; the availability of more powerful antibiotics and better support measures are in place&#44; in many cases medical treatment is a viable alternative to surgery&#46;<span class="elsevierStyleSup">3&#44;7&#44;9</span> Prolonged antibiotic treatment has a more beneficial effect on reducing morbidity and preserving renal mass and function&#46;<span class="elsevierStyleSup">7&#44;9</span> Our patient presented the three key symptoms&#58; fever&#44; side pain and pyuria&#44; which is characteristic of an upper urinary tract infection&#46; In this case&#44; apart from urinary stasis and hydronephrosis caused by the pregnancy&#44;<span class="elsevierStyleSup">5</span> there were other factors that favoured the condition like previous urinary tract infections and vesicoureteral reflux&#46; The ultrasound and MRI scan made an early diagnosis possible&#44; showing the presence of a renal corticomedullary abscess and dilatation of the upper urinary tract&#46; Close monitoring of lesions using regular ultrasound and MRI scans and ongoing&#44; rotated antibiotic treatment made it possible to successfully bring the pregnancy to term without having to resort to surgical drainage&#46;</p><p class="elsevierStylePara">In summary&#44; we have described an exceptional case of a women who was 24 weeks pregnant who presented acute pyelonephritis caused by Escherichia coli&#44; which was further complicated by a corticomedullary renal abscess&#46; The diagnosis was confirmed using ultrasound and MRI scans&#46; The ongoing antibiotic treatment made it possible to keep the pregnancy and bring it to term in the 38th week&#44; resulting in a normal live birth&#46; The patient also made a full recovery without having to resort to percutaneous drainage&#46; This case highlights that MRI scans can be useful for detecting specific urological problems like a complicated case of pyelonephritis with a renal abscess&#44; hydronephrosis and vesicoureteral reflux&#46; Given the favourable prognosis for mother and foetus&#44; this case also shows that conservative medical treatment is a viable alternative to surgery&#46; </p><p class="elsevierStylePara"><a href="grande&#47;42718078&#95;f1&#95;pag492&#46;jpg" class="elsevierStyleCrossRefs"><img src="42718078_f1_pag492.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;42718078&#95;f2&#95;pag493&#46;jpg" class="elsevierStyleCrossRefs"><img src="42718078_f2_pag493.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; 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Idiomas
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