Case Study

Ureteritis, with suspect purulent ureter in 8 year old FS DSH

This 8 year old, 4 lbs, 11 oz DSH cat presented for weight loss, lethargic, no vomiting or diarrhea, unsure of eating, family moved homes ~ 1 week ago. PE: Temp 103 two days ago, 104.7 yesterday and 102 today. Total protein 9.2. Radiograph Findings: Opacities in area of kidneys poor detail due to decreased body fat.

Image Interpretation

Left kidney measured 3.5 cm. Slight cortical infarct was noted in the left kidney. The right kidney in this patient presented hydroureter with echogenic debris was noted; likely purulent. Ureter was also thickened consistent with chronic ureteritis and stricture approximately 4 cm caudal to the right renal pelvis. Infiltrative mass is possible given the ureteral tissue thickening. Focal 0.6 cm calculus was noted at the caudal aspect of the corticomedullary junction migrating to the pelvis. Pyelectasia was noted in the right kidney with ill-defined corticomedullary definition.

The urinary bladder and visible pelvic urethra were unremarkable for the level of repletion presented. The urine, however, did present some mildly echogenic debris consistent with mucous, exfoliated cells from renal or bladder origin, and/or blood clots as these echogenic changes can all present similarly. This is often related to urinary tract infection but may represent simple evidence of exfoliated debris or sterile inflammation. Cystocentesis, urinalysis, and/or culture would be recommended top rule out and define a UTI. The urinary bladder presented a large amount of debris.

DX

Ureteritis, with suspect purulent ureter

Outcome

Right chronic ureteritis with obstructive pattern. Right renal calculus; non-obstructive currently.
Echogenic ureteral debris; suspect purulent ureter. Potential ureteral neoplasia.
Trace free fluid.

Comments

It is debatable on whether the right kidney could potentially be saved in this patient. However, I am concerned for ureteral neoplasia versus proliferative inflammatory tissue in the distal right ureter. Recommend exploratory surgery and examination of the right ureter and a judgment call as to right nephrectomy, right ureterectomy could be considered. The left kidney appears to be in adequate condition to sustain metabolic need for some time just from a subjective standpoint. IVP could also be considered to assess renal function. Concurrent pancreatitis is an issue. J-tube placement may be in the best interest of this patient as well as inspection of the pancreas. If the ureteral tissue is inflammatory in nature, it is likely derived from passage of calculi and now a purulent ureter and pyelonephritis is an issue. However, neoplastic proliferation from the right ureter can also present in this manner. No evidence of metastatic disease. Very guarded prognosis dependent upon tissue histopathology of the right ureter.

Another option would be interventional radiology approach with SUB placement for the right kidney; however, sampling of the right ureter would be necessary in this patient regardless. Broad spectrum antibiotics, pain management, and IV fluid support are all indicated until surgical intervention can occur. Both issues can be causing the clinical signs of pancreatitis and ureteral disease/pyelonephritis of the right kidney.