Chinese Medical Journal 2008;121(2):188-189
Eosinophilic ureteritis: case report
YANG Lin-bin, WU Wan-xin
YANG Lin-bin (Department of Urology, Jiaxing First Hospital, Jiaxing, Zhejiang 314000, China)
WU Wan-xin (Department of Pathology, Jiaxing First Hospital, Jiaxing, Zhejiang 314000, China)Correspondence to:YANG Lin-bin,Department of Urology, Jiaxing First Hospital, Jiaxing, Zhejiang 314000, China (Tel: 86-573-2961079. Fax:. E-mail:firstname.lastname@example.org)
Eosinophilic ureteritis is a rare disease. No cases of the disease have been reported until now in China. We present here a female case with eosinophilic ureteritis seen by our department.
In August 2004, a 30-year-old woman was admitted after 10-day pain in the right lumbar region and urgent micturition. She had no history of hypersensitivity to drugs or food and had not contacted plague water in the past.
On admission to our hospital she was emaciated, with a weight of 42 kg. Physical examination showed percussion pain over the right kidney region existed. Routine blood tests showed white blood cell count 6.8×109/L, neutrophil count and proportion 2.6×109/L and 38.5%, eosinophil count and proportion 1.23×109/L and 18.0%. Serum immunoglobulin indicated complement C3 0.45 g/L, C4 <0.10 g/L, IgG 6.70 g/L, IgE 278.1 U/ml, IgA 1.64 g/L and IgM 0.74 g/L. Worm ova were not found in the stool. Routine urine analysis showed epithelial cells “+++”. Serum creatinine was 121.6 µmol/L. A hypersonic test exhibited a 22-mm separation of the right renal sinus, with an inner diameter of the upper right ureter of 11 mm. The lumen of the middle and lower right ureter was replaced by a strip of 45 mm × 12 mm low-echo area. Color doppler flowing imaging revealed dotted blood streams and arterial streams with a speed of 15.5 cm-1∙s-1 in the area. The hypersonic test suggested right hydronephrosis with a low echo area in the middle and low ureter. 2D spiral CT imaging showed a poor boundary density presenting at the right of the uterus with a CT value of 35 Hu. Right renal pelvis and calix and upper middle ureter were dilated with a water-like density. The lower portion of the right ureter was not displayed clearly. The left ureter, bladder and uterus were normal. CT imaging suggested hydrops in the right kidney and upper middle ureter and probably a mass existed in the lower ureter (Figures 1 and 2). Plain film of kidney, ureters, bladder and intravenous pyelography showed there was no calculus shadow in the kidneys, ureters and bladder. The right renal pelvis and calyx were dilated remarkably. Lesions of the right middle and lower ureter needed further examination. The right kidney had hydrops. A renogram showed a normal right kidney and right upper urinary obstructions with high-levels of extensive shaping.
Figure 1. CT image shows the dilatation of the right pelvis, calix and upper middle portion of right ureter with watery density (arrows, CT value of 35 Hu).
After preoperative preparation, the patient received ureteroscopy, lumpectomy and replantation of the right ureter. Under ureteroscopy, the mucosa was found to be undamaged. The lower segment of the right ureter was constrictive and the upper segment was dilatated and twisted. Because no lump was found under ureteroscopy, an open operation was selected. During the operation, the wall of the lower segment of the right ureter was found to be thickened, stiff and unsmooth, with a length of 4 cm and a diameter of 2 cm. The swollen part of the ureter extended to the bladder; mimicking infiltrating cancers in appearance. After excising the swollen part and opening the lumen of the ureter, the mucosa was found intact, but the muscular layer and adventita thinkened.
The postoperative pathological examination showed chronic inflammation with numerous eosinophilic infiltration and a granulomatous reaction in the right ureter. Acid-fast test was negative (Figures 3 and 4). Postoperative count of blood eosinophils was slightly high with 0.5×109/L. The patient left hospital 7 days after operation.
Figure 2. CT image shows a dense with unclear boundary in the lower portion of right ureter beside uterus (arrow, CT value of 35 Hu).
Eosinophilic ureteritis is a rare disease. Using medical imaging, it is difficult to distinguish eosinophilic ureteritis from ureteral tumors. In the operation, the ureter wall is thick, congestive with edema, mimicking infiltrating ureteral cancers. The mucous membrane is intact. Histopathological examination is the only way to diagnose the disease that has characteristics of eosinophilic infiltration and a granuloma reaction in the wall of the ureter.1,2 The cause of the disease is unclear. But it may be associated with hypersentivity to bacteria, parasites, foods and drugs.3
This patient had eosinophilia in the peripheral blood, a decrease of complement C3, C4 and IgG and increased IgE, which suggests that eosinophilic ureteritis may be related to allergy and autoimmune.
In summary, this case suggests that eosinophilic ureteritis should be considered when a mass is found in the ureter by imaging with eosinophilia in peripheral blood, abnormal serum Ig and complement and intact mucosa in ureteroscopy. By pathology the disease should be different from the angiolymphoid hyperplasia with eosinophilia, Kimura’s disease and hypereosinophilic syndrome.
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2. Spark RP, Gleason DM, DeBenedetti CD, Gigax JH. Is eosinophilic ureteritis an entity? 2 case reports and review. J Urol 1991; 145: 1256-1260.
3. Platt ML, Kiesling VJ Jr, Vaccaro JA. Eosinophilic ureteritis associated with eosinophilic cholangitis: a case report. J Urol 1990; 144: 127-129.