Title : Beyond E. coli: Unmasking renal Actinomyces in a polymicrobial abscess
Abstract:
Actinomycosis is an uncommon infection, usually appearing in the cervicofacial, thoracic, and abdominal regions. Renal involvement of actinomycosis is an extremely rare condition, with a limited number of cases reported in literature to date. Actinomycetes species are generally of low virulence that often require disruption of mucosal barriers to establish infection and usually affect immunosuppressed individuals. Due to the indolent progression and non-specific presentation of renal actinomycosis, the diagnosis can be challenging and is frequently misdiagnosed as malignancy or chronic inflammatory diseases. Early and accurate diagnosis, and treatment initiation is necessary to avoid complications that may result in unfavorable outcomes. With the discovery of new antibiotic therapies, there has been steep decline in the incidence of nephrectomies among the patients with renal abscess, since 1995. At present, percutaneous drainage and prolonged antibiotics therapy is the standard of therapy for renal abscess. Previous studies have shown that high risk factors such as abscesses >5cm in size, obstructive uropathy, severe vesicoureteral reflux are associated with treatment failure. Rescue nephrectomy is indicated only in patients with medical failure of therapy or in patients with chronic poorly functioning pyelonephritic kidneys with scarring, as a result of chronic obstruction or recurrent infection. We report a case of a previously healthy 45-year-old male with history of chronic suprapubic catheterization, who presented with severe sepsis secondary to multiple left renal abscesses and hydroureteronephrosis, in the setting of a distal ureteral stone. Culture of the abscess fluid demonstrated growth of E. coli and Actinomyces turiensis. The patient was treated with prolonged percutaneous drainage of the left renal abscesses and 15 weeks of antibiotics, that resulted in near complete resolution of the abscesses in the left kidney. Despite the presence of high-risk factors, our patient responded well to conservative management with prolonged antibiotic therapy and percutaneous drainage and did not require nephrectomy. This case serves to highlight the diagnostic and therapeutic challenges of renal
actinomycosis, its aggressive progression with contiguous tissue spread, and the need for early multidisciplinary intervention to optimize clinical outcomes in these rare infections.
