RENAL INFARCTS* A SURGICAL ASPECT OF BACTERIAL ENDOCARDITIS

JOSEPH SCHWARTZ, M.D., P.A.C.S.

NEW YORK CITY

T HE condition under consideration is aseptic renaI infarcts, a Iesion which, because of the difficuIty in recognizing

it, frequentIy Ieads to surgica1 errors. Many surgeons must, at some time, have

experienced the chagrin of operating for a condition which definiteIy appeared surgica1 only to discover that an aseptic renaI infarct was present, compIicating some obscure systemic disease. Such embarrass- ment is sometimes shared by the cIin;cian, who not onIy requests surgica1 consuItation, but confirms the necessity for surgica1 intervention.

The septic infarct most commonIy sec- ondary to a cutaneous infection and which usuaIIy terminates in a perinephric abscess, or occasionaIIy in a carbuncIe of the kidney, wiI1 not be incIuded in this discus- sion. The Iatter is a we11 known surgica1 entity which usuaIIy occasions but IittIe diflicuIty in recognition but may never- theIess tax the surgeon’s diagnostic acumen and surgica1 judgement. The timeIy recognition and proper surgica1 manage- ment of this renaI condition is not onIy curative, but may shorten an otherwise Iong and protracted iIIness.

This paper concerns itseIf with a genera1 discussion of aseptic renaI infarcts, par- ticuIarIy those compIicating subacute bac- teria1 endocarditis as iIIustrated in the five cases reported in this paper.

It is not my purpose to discuss subacute bacteria1 endocarditis, but rather to em- phasize that in some cases this we11 under- stood and usuaIIy easiIy recognizabIe heart Iesion may be so obscured by emboIic renaI Iesions, which are rather common, as to mimic an acute primary intraperitonea1 or renaI disorder. This occurred in four of our ninety cases of bacteria1 endocarditis. The many interesting cIinica1 phases of

bacteria1 endocarditis are thoroughIy dis- cussed in the contributions by Libman, CIawson, Baehr, BeII, Thayer, LoehIein and BIumer. CIawson in a study of 220 cases of bacteria1 endocarditis found gross renaI infarcts in 26 per cent and microscopic Iesions in 55 per cent. Be11 found micro- scopic Iesions in 52 per cent. In 150 autop- sies, BIumer found renaI infarcts in sixty-four cases. In two of these the infarcts were septic. The spIeen, Iu”ngs, brain and extremities are aIso common sites of emboIic Iesions, particuIarIy the first organ.

Aseptic or non-suppurative renaI infarcts may occur in a variety of conditions, although according to our cIinica1 and post- mortem records bacteria1 endocarditis and chronic cardiac Iesions are the predominant etioIogic factors. Barney and Mintz, in an exceIIent monograph on the subject of renaI infarcts, reported severa cases and reviewed autopsy records of 143. In onIy six of these was a norma heart found; bacteria1 endocarditis and chronic vaIvuIar changes predominated. Aschner coIIected sixteen cases of renaI infarcts and reported two associated with chronic vaIvuIar Iesions of the heart. Another etioIogic factor in the production of non-suppurative renaI in- farcts as we have noted at post-mortem, was atheroscIerosis of the aorta or renaI vesseIs. In another case, renaI infarcts had their origin in a thrombophIebitic vein of the Iower extremity; thrombi had broken away and passed through a patent foramen ovaIi to Iodge in both kidneys. A thrombus was aIso arrested at the bifurcation of the aorta where it formed a saddIe back thrombus causing gangrene of both ex- tremities. Other conditions reported as giving rise to aseptic renaI infarcts are trauma, peri-arteritis nodosa and infectious

* From the Surgical and MedicaI services and the Laboratory Lebanon Hospital, N. Y. C.

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NEW SERIES VOL. XxX4X. No. I Schwartz-Rena1 Infarcts American Journal of Surgery 71

diseases. Rabinowitch reports one case with compIete infarction of the kidney caused by direct invasiun of the renaI artery by a squamous ceI1 carcinoma of the kidney.

CIinicaI and post-mortem studies in our cases indicate that there are no reIiabIe criteria avaiIabIe which might serve to distinguish aseptic renaI infarction from other common renaI disorders for which renaI infarcts are often mistaken. It is a we11 known fact that aseptic renaI infarc- tion frequentIy occurs without any sympto- matic or physica expression of its existence. For that reason the condition is more commonIy a post-mortem finding than a cIinica1 manifestation, and is therefore more famiIiar to the pathoIogist than to the surgeon or cIinician. In 64.7 per cent of the cases studied by Barney and Mintz, there was no history of pain or IocaI tenderness. In the series of cases of endocarditis re- ported by BIumer, onIy one third of those with renaI infarcts gave some cIinica1 evidence of renaI invoIvement.

The outstanding symptom, if present, is pain, the degree of which depends upon the extent of the emboIic Iesions. The char- acter of the pain does not differ from that commonIy associated with other renaI disorders such as intra-renaI or perirena1 infection or caIcuIi. The pain is usuaIIy in the Iumbar region and may simuIate an attack of renaI coIic as it did in Case I in our series. If the main renaI artery or a major branch is occIuded, severe abdomina1 pain with marked muscIe rigidity may be present, as it occurred in Case 5. This may be so pronounced as to Iead one to suspect a perforation of a viscus. In Cases 2 and 3 the pain was first so IocaIized as to simuIate an acute inff ammation of the gaI1 bIadder or appendix. LocaI tenderness over the costo- vertebra1 angIe has been consistentIy present. A striking feature in the five cases reported here was the presence of costo- vertebra1 tenderness appearing first on one side, then on the other. The presence of pain in the renaI region in those patients with bacteria1 endocarditis is not aIways

indicative of gross renaI infarcts. The occurrence of emboIic gIomeruIar Iesions so we11 described by LohIein and Baehr as characteristic of streptococcus viridans endocarditis, may cause the same degree of pain and IocaI tenderness as though gross infarcts were present. This is we11 iIIus- trated in Cases 2 and 4. Constitutiona symptoms, such as high temperature, nausea, vomiting and weakness, (a11 present in the five cases), were manifestations of the primary medica condition rather than of emboIic Iesions.

Urinary symptoms such as frequency and painfu1 urination have been present in some of the cases reported by L&man, BIumer, Aschner and others. In the series reported by Barney and Mintz g per cent had urinary symptoms.

The urine usuaIIy shows the presence of aIbumin, red bIood ceIIs, white bIood ceIIs and casts, especiaIIy if the emboIic mani- festations are secondary to bacteria1 endo- carditis. According to Baehr, most of the cases with streptococcus viridans endo- carditis, wiI1 discIose red bIood ceIIs in the urine if carefuIIy examined. Gross hemat- uria occurred in Case 4. In one third of the cases studied by Barney and Mintz, the urine was normaI.

Diagnostic means other than cIinica1 are unfortunateIy Iacking for estabIishing the presence of renaI infarcts in generaI. Routine uroIogic study is usuaIIy negative. Cystoscopy and radiographic study are generaIIy of IittIe vaIue, but serve neverthe- Iess in a negative manner by excIuding other Iesions which may be suspected. Cystoscopy was done in two of these cases and did not discIose evidence of renaI pathoIogy. Diminished renaI function wiI1 be found onIy if extensive infarction is present, or when there is considerabIe gIomeruIar damage.

Because there are Iacking characteristic cIinica1 and diagnostic features which wouId permit recognition, diagnostic errors are not onIy common but sometimes Iead to unnecessary surgery, as one might infer from the first three cases. Bishop reports an

72 American Journal of Surgery Schwartz-Rena1 Infarcts Jawmu, 1938

interesting case which was treated for a uroIogic condition for some time before it was discovered that bacteria1 endocarditis existed: Rathbun aIso reports a case operated upon for a primary renaI disorder and at operation muItipIe renal infarcts of unknown origin were found. There are probabIy many other simiIar cases which are not reported.

UnIess one considers this renaI Iesion when attempting to determine the patho- Iogic basis of urinary compIaints, it wiI1 probabIy be overIooked, especiaIIy when that systemic disorder known to give rise to renaI emboIic Iesions remains unrecognized.

Subacute bacteria1 endocarditis is the most common source of renaI infarcts. It is, therefore, of great advantage to the surgeon or uroIogist to be famiIiar with the cardina1 features of this heart Iesion so that when a renaI infarct does occur, he wiI1 recognize the association of these two conditions and avoid the pitfaIIs in diagno- sis. CarefuI co-operation between the surgeon and cIinician is not onIy desirabIe but necessary, for occasionaIIy a case of endocarditis is so obscured by emboIic Iesions that it remains undetermined unti1 post-mortem study, or unti1 an operation is performed.

Because of the persistent pain in the renaI area and eIevation in temperature, one often suspects a septic infarct or peri- nephric abscess, as in Cases I, 2 and 3. A striking feature in the cases reported here was the presence of biIatera1 costo-vertebra1 tenderness.

When the surgica1 error is committed and the surgeon at operation discovers, instead of the suspected renaI pathoIogy, a renaI infarct or “flea bitten” kidney, it is important that he appreciate the signif- icance of such pathoIogic findings, in order to avoid the unnecessary removal of the kidney in the mistaken beIief that this unfamiIiar pathoIogic aIteration justifies a radica1 procedure. Libman cites two such instances.

An aseptic renaI infarct is not an oper- ative Iesion; operation is performed when it

is mistaken for some other acute condition. Infarcts per se are of IittIe significance if associated with a benign systemic disorder, giving rise to them. It is a common post- mortem experience to find smaI1 infarct scars of Iong standing, which most IikeIy gave none or possibIy sIight and unrecog- nized cIinica1 evidence of its occurrence. Rena1 function is usuaIIy unimpaired, for these infarcts are generaIIy smaI1 and kidney destruction is sIight. In one patient, post-mortem examination discIosed con- siderabIe atrophy of one kidney, apparently of Iong duration, which was attributed to occIusion of one of the major renaI arteria1 vesseIs, the seat of severe scIerosis; this finding was accidenta and was not respon- sibIe for the death of the patient.

The seriousness of this renaI Iesion de- pends entireIy on the systemic condition responsibIe for its production. Infarcts occurring in the course of bacteria1 endo- carditis are fata because the Iatter condi- tion is a grave one.

On the basis of our post-mortem acci- denta findings of renaI infarcts or scars indicating that an infarct had occurred, there can be no doubt that this lesion occurs much more frequentIy than sus- pected. I sometimes wonder if the many patients, (especiaIIy past middIe life, when cardiovascuIar changes begin to appear), who come to us with compIaints suggesting some renaI pathology such as stone or infection, and in whom thorough uroIogic study yieIds negative resuIts except for a few abnorma1 eIements in the urine, are not instances of smaI1 renaI infarcts. AIthough this conception seems specuIative, yet cIinica1 and post-mortem studies seem to support such a view.

The foIIowing cases are briefly reported with their saIient features.

CASE I. J. K., male, 60 years oId, was admitted to the hospita1 because of pain in the Ieft Iumbar region which radiated to the groin. The pain first appeared two weeks before ad- mission and was not very severe; some reIief was obtained by the appIication of a hot water bag. Associated with this pain were chilIs and

NEW SERIES VOL. XXXIX, No. I Schwartz-Rena1 Infarcts Anxrican Journal of Surgery 73

fever. The patient appeared to be heaIthy and we11 nourished. Heart and Iungs were negative. There was pronounced tenderness over the Ieft costo-vertebra1 angIe suggesting a left kidney Iesion. Examination of the urine and blood faiIed to revea1 any abnormaIity; the temperature was 101’F. On cystoscopic and Roentgen examination, no Iesion was found anywhere in the urinary tract. His temperature continued between I~~~-Io~~F. for about one week, when it became normaI. After ten days he feIt somewhat improved, so he reIeased himseIf. After five days’ stay at home, he returned to the hospita1 feeIing much worse. He again had chiIIs and fever and now had vomited severa times. His genera1 appearance was about the same; heart and Iungs were stiI1 negative; the tenderness was quite pronounced over the Ieft costo-vertebral space, and to a Iesser degree on the right side. A few days Iater, crepitant r&Ies were heard at the bases posteriorIy but not enough to account for the septic cIinica1 course. The urine now showed some white ceIIs and occasiona casts. The bIood cuIture was negative; the temperature continued between 1oo~--103~~.

Because of the persistent and pronounced tenderness over the Ieft kidney region, it was now considered very probabIe that there was a Ieft perinephric abscess. Roentgen examination was of no assistance. This impression was somewhat supported by a rather vague history of the presence of a boi1 severa weeks before. After two weeks of observation and in the absence of other findings to account for the clinica course and the persistence of IocaI tenderness, it was deemed advisabIe to expIore the Ieft renaI region. One month after admis- sion, he was operated upon. There was no perinephric suppuration. The kidney itself, however, had severa smaI1 infarcts which was sufficient evidence that we were probabIy deaIing with subacute bacteria1 endocarditis. Five days after the operation, petechiae, which were previousIy searched for, now appeared on both Iower eyeIids and the roof of the mouth. Repeated bIood cuItures were steriIe. He con- tinued a septic course and on the tweIfth day after the operation, he died in cardiac faiIure.

Post-mortem examination discIosed a bac- teria1 (streptococcus viridans) endocarditis, muItipIe infarcts in both kidneys and micro- scopic evidence of embolic gIomeruIonephritis.

CASE II. M. E., female, 13 years oId, was admitted because of headache, fever and vomiting, which began two weeks before. During the past four days her temperature ranged between 100~-103~~. On physica exam- ination nothing was found to account for the symptoms. The urine showed a faint trace of aIbumin and some white bIood ceIIs. BIood examination was negative. The impression was that she was recovering from inffuenza. Two days after admission a ‘few rbIes were heard at the Ieft base posteriorIy and tenderness was found over the right costo-vertebral angle. The urine showed many more W. B. C. and aIbumin. In view of these findings and the temperature, the foIIowing possibiIities were considered: inff uenza, pneumonia, tuberculosis, and a right renaI or perinephric infection. Four days after admission this patient appeared acuteIy iI1. There now deveIoped an indefinite but very tender mass in the right upper quadrant which extended down towards the Iower quadrant. SeveraI petechiae were noted in the right Iower Iid and the hard p&Iate. Apparently, no significance was attached to these findings. Tenderness in the right costo- vertebra1 angle became more pronounced, and to a Iesser degree was present on the Ieft side. The red ceI1 count now ranged between 2,000,000 and 3,000,000 and white ceIIs between I 1,000 and 30,000; the hemogIobin dropped to 44 per cent. The following Iesions were now considered as IikeIy to be present: Acute ChoIecystitis, retroceca1 periappendicuIar abscess, perinephric abscess and possibIy a perforated gastric or duodena1 uIcer. After a surgica1 consuItation, it was feIt that this patient was now too sick for any operative intervention and therefore supportive measures were continued. On the sixth day after admis- sion a transfusion was given and this was foIIowed by a Iaparotomy. No intraperitonea1 lesion was found; the appendix and gaI1 bIadder were normaI. The right kidney was paIpated and found twice the norma size. The patient continued a septic course and was quite iI1. There was exquisite tenderness over the right kidney and in spite of negative Roentgen findings of the urinary tract, expIoration of the right renaI region was deemed urgent three days after the Iaparotomy. There was no perinephric suppuration. The kidney was greatIy enIarged and had a mottIed appearance; severa punctures faiIed to discIose evidence of

74 American Journal of Surgery Schwartz-Rena1 Infarcts

suppuration in the kidney proper. The foIIow- ing day the patient deveIoped a diffuse rash. BIood cuItures, which were repeatedIy steriIe, now showed a growth of 25 coIonies of B. in- fluenza per C.C. of bIood. The urine now showed many pus ceIIs, red ceIIs and granular casts. The temperature ranged between I o I ‘--I 05’~. Three days after the second operation, death occurred from a viruIent sepsis and cardiac failure. Post-mortem examination reveaIed subacute bacteria1 endocarditis invoIving the mitral vaIve and Iower surface of the aortic cusp. Crushings from the vegetations showed B. inff uenza. The spIeen had two Iarge infarcts. The kidneys had no gross infarcts but showed microscopic evidence of emboIic lesions.

CASE III. A. F., femaIe, 47 years oId, was admitted because of pain in the right upper quadrant. This pain which was present from time to time during the past eighteen months, radiated to the back and right shouIder and had no reIation to meaIs. She was told that it was due to gaI1 bIadder disease. On examina- tion, this patient appeared sick, but heart and Iungs gave no evidence of disease. There was tenderness in the right upper quadrant and right costo-vertebra1 angIe. The urine showed aIbumin+ +, pus cIumps, a few red ceIIs and granuIar casts. BIood count showed red ceIIs 4,200,000, white ceIIs 14,000, poIymorpho- nucIears g2 per cent and Iymphocytes 8 per cent. The foIIowing day the tenderness in the right upper quadrant and right costo-vertebra1 angIe became very marked; there was a severe chiI1, foIIowed by a temperature of 105’~. A bIood cuIture was steriIe and a WidaI test was negative. The impression was that there was an acute ChoIecystitis or possibIy a right kidney infection with a perinephritic abscess. About six days after admission a bIowing systoIic murmur was heard over the apex and costo- vertebra1 tenderness was now present on the Ieft side. After a medica consuItation, it was thought there was some myocardia1 invoIve- ment; the Iungs were apparently normaI. UroIogic study faiIed to estabIish any definite Iesion. Roentgen examination of the lungs, gaI1 bIadder, and spine aIso failed to revea1 any Iesion. The possibiIity of a pyIephIebitis secondary to a high retroceca1 acute appendi- citis was aIso considered. About eighteen days after admission, abdomina1 expIoration, which seemed to be justifiabIe because of the per- sistent abdomina1 signs, discIosed a norma

appendix and gaI1 bIadder. The right kidney feIt enIarged. The patient continued a cIinica1 course suggesting a sepsis of unknown origin. The red ceI1 count now was diminished to two miIIion, white ceIIs eIevated to 2 I ,000; repeated bIood cuItures were steriIe; urine findings were the same as on previous examinations. Trans- fusions were given, but the patient died six weeks after admission from cardiac faiIure.

Post-mortem examination disclosed bacteria1 endocarditis. The crushings of the valves showed biscuit shaped organisms. The kidneys and spIeen had infarcts whiIe there was microscopic evidence of gIomeruIonephritis.

CASE IV. J. S., maIe, 27 years oId, became iI six weeks before with a sore throat and temperature 103%., folIowed a few days Iater by painfu1 swoIIen joints. One week before admission, he passed smoky urine. On examina- tion this patient did not appear acuteIy iI1; the Iungs were norma and the heart showed no evidence of any organic Iesion. BiIateraI costo- vertebra1 tenderness was present. AbdominaI paIpation gave no evidence of any intra- abdomina1 condition. The extremities showed areas of muscIe tenderness and some pain on motion of the Iarger joints. The urine showed albumin, red ceIIs, white ceIIs and granuIar casts. BIood examination reveaIed red ceIIs, 3,600,000 white ceIIs 13,600, poIymorpho- nucIears 84 per cent, Iymphocytes 16 per cent, and hemogIobin 70 per cent. The temperature was IO IOF., the bIood pressure 160 systoIic and I I o diastoIic.

The impression was that he began with a streptococcus sore throat which was com- pIicated by gIomeruIonephritis and infectious arthritis. For the foIIowing tweIve days his condition remained the same; the temperature ranged between 100’~. and 102’~. He then suddenIy went into coIIapse; his puIse was very rapid and weak; he appeared very paIe and compIained of severe abdomina1 pain. The urine was grossIy bloody. His condition was thought to be due to myocardia1 failure or impending uremia; the bIood pressure feII to 70 systoIic and 40 diastoIic. The foIIowing day the pain became more intense and a mass deveIoped in the right ffank which was very tender. It was now seriousIy considered that there might be an emboIic Iesion in the right kidney or mesenteric vesseIs secondary to a subacute endocarditis. The mass was accounted for by bIood extravasation. The mass continued

NEW SERIES VOL. XXXIX, No. I Schwartz-Rena1 Infarcts American Journal of Surgery 75

to increase in size, became more irreguIar and tender and extended from above the umbiIicus to the peIvis; some rigidity was present directIy over the mass. Eight days after the onset of this abdomina1 compIication, the abdomen was explored and it was found that this mass was an extensive retroperitonea1 hematoma surrounding the kidney. It was evacuated and drained.

The patient’s condition did not permit any extensive search for the source of this bIeeding. Periateritis nodosa of the renaI artery was strongIy considered as an etioIogic factor. The patient appeared more comfortabIe after the operation. By this time a Ioud blowing systoIic murmur was heard at the apex transmitted to the axiIIa. The red ceI1 count and hemo- gIobin had dropped considerabIy. The possi- biIity that this was a functional murmur was considered. Transfusions were given. Sixteen days after the operation, during which time the wound was draining a sero-sanguinous dis- charge, there occurred a severe hemorrhage from the wound which was controIIed by pack- ing. During the next six weeks, the patient continued a septic course and had severa more hemorrhages from the wound. The hemoglobin had dropped to IO per cent, red ceIIs to 1,300,- ooo; the pIateIet count was 350,000. Repeated transfusions were given. The patient’s condi- tion was too critica to permit adequate expIoration of the renaI area in an attempt to find the bIeeding point. Repeated bIood .cuI- tures were steriIe. The subsequent clinica course was that of a sepsis of unknown origin, subacute endocarditis with emboIic mani- festations being strongIy considered. About fourteen weeks after admission, he died of exsanguination.

On post-mortem examination the foIIowing conditions were found: subacute endocarditis on an oId rheumatic mitra1 valve, emboIus of the mesenteric artery with an aneurysm which ruptured, forming a Iarge hematoma in the mesentery, perirena1 and subhepatic areas. The kidneys showed no gross emboIic Iesions but microscopicaIIy showed extensive gIomeru- Iar damage.

CASE v. A. I., maIe, 58, was admitted com- pIaining of pain on the Ieft side of the neck and precordium, radiating down the Ieft arm for the past week. He had rheumatism at the age of 14. On examination he appeared emaciated; there was tenderness over the cervica1 vertibrae.

The Iungs showed no evidence of disease; there was a systoIic murmur at the apex transmitted to the Ieft axiIIa; abdomina1 examination was negative. The urine showed a few white bIood ceIIs and a trace of aIbumin; the bIood findings were negative. The bIood pressure was 155 systoIic and IOO diastoIic. The cIinica1 impres- sion was that of an arterioscIerotic heart, rheumatic endocarditis and cervica1 arthritis. The Iatter was confirmed by x-ray examina- tion. EIectrocardiographic study discIosed a sinus rhythm. He continued for five weeks with a Iow grade temperature and without further physica evidence of any organic Iesion. Sub- acute bacteria1 endocarditis was aIso con- sidered. G.C. compIement fixation and the Wasserman were negative. A nonhemoIytic streptococcus was found in the fluid expressed from his prostate. He reIeased himself after five weeks without feeling improved.

One month Iater, he returned with identica1 compIaints as before; marked weakness was now present. His physica status had not changed. Laboratory findings were now as foIIows: urine showed a heavier trace of aIbumin with some red and white ceIIs and casts, and there was now a moderate anemia. SeveraI bIood cuItures in the next few weeks were sterile. About two weeks after this admis- sion he was suddenIy seized with severe agon- izing pain in the Ieft side of the abdomen and Iumbar region. His temperature which ranged between gg” and IOI’F. suddenIy rose to 104’~. There was marked rigidity of the Ieft haIf of the abdomen with pronounced tenderness most marked in the Ieft costo-vertebra1 space. In view of the suspicion that this patient might have subacute endocarditis, the surgica1 opinion was ventured that there might be an emboIic Iesion of the Ieft kidney with a resuItant infarct. A caIcuIous obstruction and pyelo- nephritis and septic infarct were aIso con- sidered. This patient appeared very III. There was no indication for surgica1 intervention. After one week there was gradua1 improve- ment; the IocaI tenderness and rigidity gradu- aIIy subsided. There was sIight tenderness in the right costo-vertebra1 angIe. His condition now permitted x-ray study of the urinary tract. This faiIed to discIose any caIcuIus, perinephric abscess, or carbuncIe. His condition wouId not permit cystoscopic study. He continued a septic course, the temperature ranging between gg’ and 104’~. Four more

76 American Sournaf of Surgery Schwartz-Rena1 Infarcts

bIood cultures taken a few weeks before death of this renaI I&on is showed many coIonies of staphyIococcus aIbus. order to avoid not He continued downhi and died in Ieft ven- surgery, but needIess tricuIar faiIure.

On post-mortem examination the foIIowing nostic procedures.

JANUARY, 1938

highIy desirable in 0nIy unnecessary

instrumenta diag-

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