腹部螺旋CT平扫在上尿路真菌感染并发梗阻诊治中的意义

Abdominal MSCT Scan in the Diagnosis and Treatment of Obstructing Upper Urinary Tract Fungal Bezoars

目的:总结并归纳上尿路真菌感染并发梗阻的CT影像学表现,评价上腹部多层螺旋CT(MSCT)薄层平扫在该类疾患诊断中的意义。方法:回顾性研究2007年4月～2009年12月诊治的4例肾盂-输尿管真菌球并发上尿路梗阻患者,男女各2例,均为单侧。术前均行腹部MSCT平扫,具体扫描参数为:120 kV,280 mA,重建层厚1.25 mm,螺距1.375:1,窗宽360 HU,窗位60 HU。4例患者均通过患侧经皮肾造瘘术(PCN)控制感染,取尽真菌球,解除上尿路梗阻。结果:4例患者腹部CT平扫均提示患肾积水,患肾体积增大,肾周筋膜增厚,脂肪囊模糊,脂肪囊内可见条纹状高密度影。患肾集合系统可见散在高密度影,患侧肾盂-输尿管连接部(UPJ)可见团块状高密度影,CT值为180～235 HU。肾实质内无液性坏死及脓肿形成。4例标本中均发现真菌菌丝且念珠菌培养阳性。治疗过程中无患者出现药物相关性肝肾功能损害。结论:传统的静脉尿路造影易将上尿路真菌球误诊为上尿路肿瘤性病变或上尿路结石;腹部MSCT平扫简单易行,几乎适用于妊娠外的所有患者,结合CT值的判读可减少误诊。同时,集合系统的三维重建又大大简化了穿刺目标肾盏的选取,使该类患者能得到最恰当的诊治,减少医源性全身真菌播散性感染的可能。

Objective：To summarize the characteristics of MSCT of the upper urinary tract fungal bezoars and to evaluate the feasibility and clinical value of MSCT in the diagnosis and treatment of obstructing renal fungal ball. Methods： A retrospective study of 4 cases with upper urinary collecting system fungal bezoars complicating urinary tract obstruction from April 2007 to December 2009. 2 males and 2 females were enrolled in this study and in all the cases, the obstruction was unilateral. Case 1 ： female, 37 year old, came to the emergency room for high fever and pyonephrosis with a surgical history of percutaneous nephrostomic lithotomy in the right kidney 6 months ago. The patient had a medical history of dermatomyositis treated by corticosteroid. Case 2： Female, 42- year-old with DM, came to the clinic for right ureteropelvic junction obstruction and hydronephrosis. Case 3. Male, 57-year-old, came to the clinic for left ureteral stone and left hydronephrosis. Case 4： Male, 52-year-old, consult in the ER for anuria with right unique kidney. The MSCT without enhancement was realized in all the 4 cases. The GE Light Speed 16 CT was used in these cases with the following parameters： 120 kV, 280 mA, 1.25 mm reconstruction slice, 1. 375 ： 1, window width 360 HU,window site 60 HU. Results：In all the 4 cases, MSCT showed that the infected kidney was enlarged with a hydronephrosis. The perinephretic fascia was thick and some high density lines could be found in the perinephretic fat tissue. Some high density mass could be recognized in the collecting system as well as the UPJ junction with a CT value of 180-235. There was no parenchymal necrosis or abscess found in the kidney. The PCN drainage and local irrigation of anti-fungal medication was realized in all the cases to control the severe infection and the fungal bezoars were extracted by the percutaneous access. The urine fungal culture was positive in all the cases. These were no systemic fungal infection or massive haemorrhage during the peri-operative phase. No medication-related kidney or liver impairment was found. Conclusions：The MSCT was widely available and almost suitable for all the cases except for the pregnant women. The CT value could help to make the right diagnosis of fungal bezoars, which makes the managements of such patients more correct, suiable and safe.