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MR Imaging of Bilateral Renal Malacoplakia After Liver Transplantation

Thomas Jefferson University Hospital Philadelphia, PA 19107
Yamaguchi University School of Medicine Yamaguchi 755-8505, Japan
Thomas Jefferson University Hospital Philadelphia, PA 19107

A 57-year-old man with negative markers for viral hepatitis presented with liver dysfunction. Biopsy of the liver revealed cryptogenic cirrhosis. After liver transplantation, he had repeated episodes of flank pain with elevated levels of serum creatinine, which were attributed to pyelonephritis although no causative organism was identified. The patient had no history of bladder or urethral abnormality or renal failure. During a posttransplantation check-up 3 years after the operation, a left renal mass was detected on sonography.

MR imaging of the abdomen with special attention to kidneys was performed on a 1.5-T unit (Signa; General Electric Medical Systems, Milwaukee, WI) using a multicoil array. After coronal localization, T1- and T2-weighted images of the abdomen were obtained. In addition, after administration of IV contrast material, a three-dimensional dynamic study was obtained in the axial plane and delayed T1-weighted sagittal images were obtained.

Both kidneys had irregular contour. Renal parenchyma had intermediate signal intensity bilaterally on T1- and T2-weighted images. In the left kidney, a 40-mm poorly demarcated mass with intermediate signal intensity was revealed on T1- and T2-weighted images. (Figs. 1A and 1B). On dynamic study (Fig. 1C), disappearance of the corticomedullary junction was noted during the arterial phase. In addition to the 40-mm left renal mass, numerous small parenchymal nodules were visible in both kidneys during the delayed phase (Fig. 1D). The most likely diagnosis was transplantation-related lymphoproliferative disorder. Biopsy of the left kidney was performed for confirmation. Numerous Michaelis-Gutmann's bodies were shown using periodic acid-Schiff stain, which lead to diagnosis of renal malacoplakia.

View larger version (66K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —57-year-old man with renal malacoplakia after liver transplantation. Axial in-phase spin-echo T1-weighted MR image (TR/TE, 130/4.2) shows both kidneys have irregular contour. Poorly demarcated mass with intermediate signal intensity is revealed (arrow).

View larger version (68K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —57-year-old man with renal malacoplakia after liver transplantation. Axial respiratory-triggered fast spin-echo T2-weighted MR image (3571/140) shows renal parenchyma has unremarkable appearance.

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —57-year-old man with renal malacoplakia after liver transplantation. Axial contrast-enhanced arterial phase gradient-recalled echo T1-weighted MR image (156/1.5; flip angle, 90°) shows corticomedullary junction is no longer visible.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —57-year-old man with renal malacoplakia after liver transplantation. Sagittal contrast-enhanced delayed phase gradient-recalled echo T1-weighted MR image (156/1.5; flip angle, 90°) shows numerous small parenchymal nodules in right kidney.

Malacoplakia is a rare chronic inflammatory disease first described by Von Hansemann in 1903 [1]. The clinical and radiologic findings of malacoplakia are often suggestive of neoplasm. Altered immune mechanism is an implicated predisposing factor. Urinary tract infection, especially with Escherichia coli, is strongly associated with this entity [2].

Multiphasic contrast-enhanced dynamic MR imaging was effective in depicting the disappearance of the corticomedullary junction and multiple small nodular lesions in the kidney, thus revealing the diffuse distribution of the disease. Images obtained using this technique may provide a better understanding of the distribution of the multinodular type of renal malacoplakia and may increase its radiologic prevalence.

References

1. Von Hansemann D. Uber malakoplakie der harnblase. Virchows Arch 1903;173:302
2. Dobyan DC, Thurong LD, Ekunoyan G. Renal malakoplakia reappraised. Am J Kidney Dis 1993;22:243 -252[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kamishima, T. Articles by Mitchell, D. G. Search for Related Content PubMed PubMed Citation Articles by Kamishima, T. Articles by Mitchell, D. G. Social Bookmarking                      What's this?