Paper II — 2024 June (Supplementary) (2019 Scheme) — Q4

Paper II

2024 June (Supplementary) (2019 Scheme) · 100 marks · 180 min

Question

Pyelonephritis

Q48 marksShort Essays★✓

Answer

Pyelonephritis is inflammation of the renal parenchyma and pelvicalyceal system, caused by bacterial infection (most commonly E. coli and other gram-negative organisms).

Acute pyelonephritis:

• Pathogenesis: Most often ascending infection from the lower urinary tract (aided by vesicoureteric reflux, obstruction, catheterization); less commonly haematogenous spread.
• Gross: Kidney shows patchy, yellowish-white abscesses on the cortical surface, often in a wedge-shaped distribution.
• Microscopy: Neutrophilic infiltration within the renal tubules and interstitium; abscess formation; tubules may be filled with neutrophilic casts (a hallmark feature). Glomeruli are typically spared (relatively resistant to bacterial infection).
• Clinical: Fever, flank pain, dysuria, costovertebral angle tenderness; pyuria and bacteriuria on urinalysis.
• Complications: Papillary necrosis (especially in diabetics, sickle cell disease, analgesic abuse, obstruction), perinephric abscess, pyonephrosis, urosepsis.

Chronic pyelonephritis:

• Results from recurrent/persistent infection, usually with underlying vesicoureteric reflux (reflux nephropathy) or chronic obstruction (chronic obstructive pyelonephritis).
• Gross: Irregular, coarse, U-shaped (broad, depressed) cortical scars, characteristically overlying blunted/dilated calyces, asymmetric involvement.
• Microscopy: Interstitial fibrosis and chronic inflammation, tubular atrophy with “thyroidization” (dilated tubules filled with pink colloid-like casts resembling thyroid follicles), periglomerular fibrosis, and eventually glomerulosclerosis.
• Outcome: Progressive scarring can lead to hypertension and chronic kidney disease.

Related Concepts

1. 1Chronic and Granulomatous Inflammation

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