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CASE REPORT
Year : 2015  |  Volume : 30  |  Issue : 3  |  Page : 266-267  

Acute lobar nephronia in renal transplant: Gallium-67 scintigraphy for diagnosis and therapy monitoring


Department of Radiology and Medical Imaging, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia

Date of Web Publication11-Jun-2015

Correspondence Address:
Saleh Othman
Department of Radiology and Medical Imaging, King Saud University, King Khalid University Hospital, Riyadh, P.O. Box: 7805 (46)
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.158542

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   Abstract 

A 33 years old female patient with chronic renal transplant rejection proved by MAG3, ultrasound and graft biopsy presented with abdominal pain and fever. Part of her work up included gallium-67 scan which revealed diffuse abnormal graft uptake with multifocal areas of marked uptake. Findings were interpreted as acute lobar nephronia. Repeat gallium scan two weeks after intravenous antibiotic therapy showed significant response reflected by resolution of most of focal areas of increased uptake which was parallel to clinical improvement.

Keywords: Acute lobar nephronia, gallium-67 scan, renal transplant


How to cite this article:
Othman S. Acute lobar nephronia in renal transplant: Gallium-67 scintigraphy for diagnosis and therapy monitoring. Indian J Nucl Med 2015;30:266-7

How to cite this URL:
Othman S. Acute lobar nephronia in renal transplant: Gallium-67 scintigraphy for diagnosis and therapy monitoring. Indian J Nucl Med [serial online] 2015 [cited 2019 Dec 6];30:266-7. Available from: http://www.ijnm.in/text.asp?2015/30/3/266/158542


   Introduction Top


Urinary tract infection is a known complication of renal transplant. Among these infections is an acute focal nephritis which also known as acute lobar nephronia (ALN). Ultrasound, computerized tomography (CT), and gallium-67 (Ga-67) scintigraphy are important tools in diagnosis of ALN. We report the use of Ga-67 scintigraphy in diagnosis and therapy monitoring of a patient with renal transplant and ALN.


   Case report Top


We report a case of a 33-year-old female patient who had chronic renal impairment and received a cadaveric renal transplant 14 months before presentation. She presented with abdominal pain, fever, leukocytosis, and elevated serum urea and creatinine, and urine analysis on admission was unremarkable. She was hospitalized, and part of her work up included renal transplant ultrasound, renal transplant Tc-99m mercapto acetyl tri glycine study, and graft biopsy. Investigations revealed chronic rejection but failed to determine the cause of fever. Ga-67 scintigraphy was ordered to search for a source of infection. Whole body and spot view of the renal graft was performed 24 and 48 h postintravenous injection of 4 mCi (148 Mbq) Ga-67 using a gamma camera equipped with low energy general purpose collimator (Brightview-Phillips). Scan 48 h postinjection revealed diffuse abnormal graft uptake with multifocal areas of marked uptake [Figure 1]. Findings were interpreted as ALN. Ultrasound done was reported unremarkable. Repeat Ga-67 scintigraphy following the same protocol of the first scan 2 weeks after intravenous antibiotic therapy showed significant response reflected by resolution of most of the focal areas of increased uptake [Figure 2] which was parallel to clinical improvement.
Figure 1: Gallium scan revealed abnormal diffuse uptake in the renal graft in right iliac fossa with multifocal areas of increased uptake in upper and lower pole (arrows). Findings were suggestive of multifocal acute lobar nephronia

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Figure 2: A repeat gallium-67 scintigraphy after 2 weeks of intravenous antibiotic therapy showed a significant response with resolution of almost all the focal areas of increased uptake in pretherapy scan (arrows) indication of good response. The patient was shifted to oral antibiotics and to be seen in the clinic after 2 weeks

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   Discussion Top


Rosenfield et al. in 1979 described a case of focal nephronia. [1] Thereafter, several radiological reports have described this entity which was also called ALN, acute focal bacterial nephritis or focal pyelonephritis. The process can affect one lobe (unifocal) or more than one lobe (multifocal). [2],[3] The disease is an inflammatory condition which precede the formation of renal abscess. [4] Clinically, the patient with ALN usually presents with flank pain and fever with leukocytosis and urine bacteriuria. ALN in renal transplant and its management has been reported by several authors. [5],[6] The diagnosis usually confirmed by radiological examinations including ultrasound, CT, and nuclear medicine tests. Ultrasound is of vital importance in the diagnosis and in follow-up of treated cases. However, ultrasound is operator dependent but can give us accurate information by expertise. Ultrasound usually suggests the diagnosis, but false positive and false negative cases have been reported. [1],[7]

Computerized tomography scan with contrast is of limited use when serum creatinine is elevated. Technetium-99m dimercaptosuccinic acid studies are more useful in the follow-up of the infected kidney rather than for initial diagnosis. [8] Ga-67 scintigraphy 48 h postinjection has been described to concentrate in the kidneys in several disease conditions such as inflammation, pyelonephritis, lymphoma, and other tumors as well as in acute tubular necrosis and chronic rejection of renal transplant. [9],[10]

Chiffoleau et al. found that Ga-67 scintigraphy was a useful tool in detecting renal transplant suppurations and can guide abscess localization by renal graft ultrasound. [11]

Gallium-67 scintigraphy was very useful in the diagnosis and therapy monitoring of our patient with renal transplant patients and ALN.

 
   References Top

1.
Rosenfield AT, Glickman MG, Taylor KJ, Crade M, Hodson J. Acute focal bacterial nephritis (acute lobar nephronia). Radiology 1979;132:553-61.  Back to cited text no. 1
    
2.
Zaontz MR, Pahira JJ, Wolfman M, Gargurevich AJ, Zeman RK. Acute focal bacterial nephritis: a systematic approach to diagnosis and treatment. J Urol 1985;133:752-7.  Back to cited text no. 2
    
3.
Kline MW, Kaplan SL, Baker CJ. Acute focal bacterial nephritis: Diverse clinical presentations in pediatric patients. Pediatr Infect Dis J 1988;7:346-9.  Back to cited text no. 3
    
4.
Shimizu M, Katayama K, Kato E, Miyayama S, Sugata T, Ohta K. Evolution of acute focal bacterial nephritis into a renal abscess. Pediatr Nephrol 2005;20:93-5.  Back to cited text no. 4
    
5.
Thomalla JV, Gleason P, Leapman SB, Filo RS. Acute lobar nephronia of renal transplant allograft. Urology 1993;41:283-6.  Back to cited text no. 5
    
6.
Tai HC, Yang PJ, Lee PH, Chung SD, Chueh SC, Yu HJ. Acute lobar nephronia in a renal allograft: A case report and literature review. Transplant Proc 2008;40:1737-40.  Back to cited text no. 6
    
7.
Soulen MC, Fishman EK, Goldman SM, Gatewood OM. Bacterial renal infection: Role of CT. Radiology 1989;171:703-7.  Back to cited text no. 7
    
8.
Mutari GA, Zaki M, Youssef T. A young girl with acute lobar nephronia. Kuwait Med J 2002;34:153-5.  Back to cited text no. 8
    
9.
Frankel RS, Richman SD, Levenson SM, Johnston GS. Renal localization of gallium-67 citrate. Radiology 1975;114:393-7.  Back to cited text no. 9
    
10.
George EA, Codd JE, Newton WT, Donati RM. 67Ga citrate in renal allograft rejection. Radiology 1975;117:731-3.  Back to cited text no. 10
    
11.
Chiffoleau S, Chatal JF, Talmant C, Vasseur F, Soulillou JP. The respective roles of gallium 67 citrate scanning and diagnostic ultrasound in detecting suppurations in renal allograft recipients. Pathol Biol (Paris) 1980;28:155-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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