USMLE® Step 1 style questions USMLE
A 45-year-old woman presents to the clinic with flank pain, malaise, and weight loss over the past several weeks. She states, “I just have no appetite for anything these days.” She has a history of recurrent urinary tract infections and several episodes of nephrolithiasis. Her temperature is 38°C (100.4°F), pulse is 94/min and blood pressure is 154/62 mmHg. Physical examination shows a palpable left sided flank mass. She subsequently undergoes a biopsy of the mass with the following histologic finding demonstrated below:
Reproduced from: Wikipedia
Which of the following pathogens is most commonly implicated in this disease process?
Chronic pyelonephritis exam links
Content Reviewers:Rishi Desai, MD, MPH
Contributors:Tanner Marshall, MS
With chronic pyelonephritis, pyelo- means pelvis, and -neph- refers to the kidney, so in this case it’s the renal pelvis, which is the funnel-like structure of the kidney that drains urine into the ureter, and -itis means inflammation. This inflammation is usually caused by bacterial infection of the kidney, which is called acute pyelonephritis.
When somebody has recurrent episodes of acute pyelonephritis, the kidney becomes visibly scarred, at which point it’s referred to as chronic pyelonephritis.
Now a urinary tract infection, or UTI, is any infection of the urinary tract, which includes the upper portion of the tract—the kidneys and the ureters, and the lower portion of the tract—the bladder and urethra.
So acute and chronic pyelonephritis are types of upper urinary tract infection.
Now, an episode of acute pyelonephritis often clears up without much complication. Certain people, though, are predisposed to having recurring bouts of acute pyelonephritis, which eventually leads to chronic pyelonephritis and permanent scarring of the renal tissue.
The most common risk factor for recurrent acute pyelonephritis and therefore chronic pyelonephritis, is vesicoureteral reflux, or VUR, which is where urine is allowed to move backward up the urinary tract, which can happen if the vesicoureteral orifice fails.
The vesicoureteral orifice is the one-way valve that allows urine to flow from each ureter into the bladder, but not in the reverse direction.
VUR can be the result of a primary congenital defect or it can be caused by bladder outlet obstruction, which increases pressure in the bladder and distorts the valve.
That being said, chronic obstruction is its own independent risk factor for chronic pyelonephritis.
Obstructions in the urinary tract causes urinary stasis, meaning it tends to cause urine to stand still, which makes it easier for bacteria to adhere to and colonize the tissue, making lower UTIs more likely and therefore upper UTIs more likely.
Bilateral obstruction increases pressure in the bladder and therefore affects both kidneys, causes include congenital malformations, like posterior urethral valve, which obstructs the flow of urine through the urethra, as well as benign prostatic hyperplasia in men, which is an enlarged prostate, and cervical carcinoma in women, both of which can compress the urethra shut.
- "Robbins Basic Pathology" Elsevier (2017)
- "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
- "Pathophysiology of Disease: An Introduction to Clinical Medicine 7/E (ENHANCED EBOOK)" McGraw Hill Professional (2014)
- "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
- "Xanthogranulomatous Pyelonephritis: Clinical Experience with 41 Cases" Urology (2008)
- "Risk Factors Associated with Acute Pyelonephritis in Healthy Women" Annals of Internal Medicine (2005)
- "Diagnosis and Management of Acute Ureterolithiasis" American Journal of Roentgenology (2000)
- "Vesicoureteral Reflux, Reflux Nephropathy, and End-Stage Renal Disease" Advances in Urology (2008)