T H E AMERICAN JOURNAL OF CLINICAL PATHOLOGY
Vol. 39, No. 6, pp. 616-625
June, 1963
Copyright © 1963 by The Williams & Wilkins Co.
Printed in U.S.A.
XANTHOGRANULOMATOUS PYELONEPHRITIS
S. M. SAEED, M.D., B.S., AND GERALD FINE, M.D.
Department of Pathology, Henry Ford Hospital, Detroit, Michigan
Changes in the color of organs have always
attracted the attention of pathologists and
have led to such terms as brown induration
and atrophy, xanthelasma, and so on. They
are produced by substances that can be
classified into 2 groups, lipids and hemochromogens, and mixtures of the 2 lead to a
variety of shades of color. Although they are
normally present in small quantities in
many organs, lipids attract attention only
when present in abnormal amounts. In this
paper we are presenting the clinical and
morphologic features of an infrequently
described entity referred to as pseudoxanthoma,12 xanthogranulomatous pyelonephritis, 6, "• I5, 19 foam cell granuloma,2 ' 8
xanthic lesion,10 and "Staphylomykosen." 18
It is characterized by nodular or diffuse replacement, or both, of the kidney parenchyma by cellular tissue rich in lipids. Although lipid-containing cells may be found
associated with specific and nonspecific
inflammation and with benign and malignant neoplasms of the kidney, the intensity
of the color change is in no way comparable
to that seen in xanthogranulomatous pyelonephritis.
blood cell and 1 + albumin; the specific
gravity was 1.015. The calculus was removed
through a resectoscope, and bilateral ureteroceles were unroofed. The patient was
readmitted in 1959 with urinary incontinence and metastases from a colonic carcinoma that had been resected in 1956; she
died 4 months later. During the last admission intravenous pyelograms revealed a
nonfunctioning right kidney, which had
diminished slightly in size, and a normal left
kidney. The urine on several occasions contained a rare white blood cell and red blood
cell, 2 + albumin, and numerous bacteria;
the specific gravity was 1.010 to 1.015.
The past history disclosed bouts of right
upper quadrant pain attributed to a poorly
functioning gallbladder. The hemoglobin,
white blood count, and differential and red
blood count were normal on 2 occasions.
The blood pressure varied between 140 and
160/90 to 105 mm. of Hg.
A large intra-abdominal carcinoma was
found at autopsy compressing and infiltrating the neck of the urinary bladder. Metastases were present in the retroperitoneal
lymph nodes. The right kidney had a most
The rarity of the lesion is illustrated by unusual appearance (Fig. 1). Its weight was
the fact that only 31 similar cases 2 " 6,8 ~ u ' 370 Gm., its dimensions were 15.3 by 7 by
is, is, 2i, 25 h a v e been found in the literature. 5.2 cm., and it had a greatly thickened adherent capsule and perirenal fat. The parenR E P O R T O F CASES
chyma was extensively replaced by wellCase 1. M.R. (HFH A59-432), a 48-year- defined irregular yellow tissue and the
old white woman, presented herself in 1953 calyces and pelvis were filled with irregular
with right costovertebral angle tenderness masses of soft yellow-grey material. The
of 3 years' duration; unassociated with ureter was dilated and the pelvic mucosa
dysuria or hematuria. The kidneys were congested. The weight of the left kidney
promptly outlined in the intravenous pyelo- was 200 Gm., its dimensions were 14.2 by
gram, and a dilated right ureter and right 7.8 by 4.6 cm., and the organ contained small
ureteral calculus were seen. The urine con- arteriosclerotic cortical scars. The mucosa
tained an occasional white blood cell and red of the urinary bladder was congested and
thickened.
Received, August 31, 1962; accepted for publication March 1, 1963.
Dr. Fine is Senior Associate in Pathology. Dr.
Saeed is Associate Professor of Pathology, Wayne
State Medical School, Detroit, Michigan.
Case 2. R.M.V., a 43-year-old colored
woman, was seen at the Oak Ridge Hospital
in Oak Ridge, Tennessee, in March 1960,
with recurrent urinary tract infection, left
616
June 1963
XANTHOGRANULOMATOUS PYELONEPHRITIS
617
FIG. 1. Case 1. Calyces and pelvis are dilated, hemorrhagic, and irregular. Cortical
medullar}' demarcation is obscured. Numerous bright yellow bulging nodules are
scattered throughout the cortex and medulla.
costovertebral angle tenderness, and a
weight loss of 90 lb. during a period of 6
months. Intravenous and retrograde pyelograms and cystoscopy revealed a calculus
2.5 cm. below the ureteropelvic junction and
slight hydronephrosis in a nonfunctioning
left kidney. Exploration disclosed the presence of a large extremely adherent mass that
encircled a portion of the aorta in the region
of the left kidney. A subcapsular nephrectomy was performed. The postoperative
course was unremarkable.
In addition to the kidney, 2 large, yellow,
necrotic-appearing masses surrounded by
thick fibrous tissue and measuring 15 by 12
by 6 and 6 by 5 by 2 cm., were removed.
The weight of the kidney was 137 Gm., and
its dimensions were 6 by 5 by 2 cm. The
capsule and perirenal tissue were 2 and 4 cm.
thick, respectively. Numerous irregular, elevated, greasy, yellow nodules, intermixed
with thick white fibrous tissue, replaced a
considerable part of the kidney. The calyces
and pelvis were thickened and an occasional
calyx contained viscid yellow fluid and
several impacted calculi. The renal pedicle
could not be recognized owing to the large
amount of scar tissue.
Case 3. A.J.S. (HFH S60-7384), a 58-yearold white man, was admitted in November
1959 with severe intermittent pain in the
right flank and right lower quadrant of 1
week's duration. Physical examination disclosed a pulse of 90 per min., temperature
of 98 F., blood pressure of 165/105 mm. of
Hg, Grade II arteriosclerotic changes in the
ocular fundi, and a Grade I soft blowing
apical systolic murmur. A firm, pulsating
aneurysm, 8 by 16 cm., extending from T12
to the aortic bifurcation, was discovered
by means of abdominal palpation and confirmed by aortography. A 10-min. intravenous pyelogram was normal. Abdominal
aneurysmectomy and splenectomy were
618
Vol. 39
SAEED AND FINE
performed. During the operation the renal
artery was seen to be involved by the
aneurysm. The right renal artery was the
site of severe arteriosclerosis that interfered with the anastomosis. Postoperatively,
the blood urea nitrogen fluctuated between
19 and 49 mg. per 100 ml. One month after
the aneurysmectomy, an intravenous pyelogram revealed nonvisualization of the right
kidney. The urine specific gravity was 1.014,
pH 5, albumin 2 + , sugar negative and
containing numerous red blood cells, white
blood cells, and bacteria. On subsequent
outpatient visits, the only complaints were
occasional occipital headaches. Three
months later, the right renal artery could
not be visualized in the aortogram. On
July 4, 1960, he noted chest pressure, pain,
and loss of consciousness. Examination
revealed facial twitching, blood pressure of
172/82 mm. of Hg, and a blood urea nitrogen
of 70 mg. per 100 ml. On conservative treatment the patient's condition improved.
The blood urea nitrogen fell to 19 mg. per
100 ml. Catheterization of the right ureter
was unsuccessful owing to stricture at the
lower end. A right nephrectomy was performed and was followed by an uneventful
recovery.
The specimen consisted of a distorted
mass of central gray and peripheral yellowpink tissue; its weight was 60 Gm., and its
dimensions were 7 by 5 by 2 cm. No renal
tissue was recognized. A thin round cord,
3 mm. in diameter, represented the ureter.
Case 4- R.S. (HFH S60-6864), a 52-yearold white man, was admitted to the Henry
Ford Hospital on May 31, 1960, with severe
lower abdominal pain, fever, dysuria, and
urgency of 4 days' duration. Physical examination revealed a temperature of 100 F.,
pulse of 84 per min., and blood pressure of
130/80 mm. of Hg. A review of systems
revealed periumbilical tenderness. Laboratory data revealed the following: hemoglobin, 12.9 Gm. per 100 ml.; white blood
count, 11,600 per cu. mm. with 88 per cent
neutrophils, 8 per cent lymphocytes, and
2 per cent monocytes; urine specific gravity
1.020, pH 5.5, albumin 4 + with many white
blood cells, red blood cells, and epithelial
cells; blood urea nitrogen, 26 mg. per 100
ml. Inti'avenous pyelogram on June 13,
1960, revealed a nonfunctioning right kidney
and conspicuous calcification of the renal
arteries. A retrograde pyelogram revealed a
cystic cavity measuring 6.5 by 5.5 cm. On
July 11, 1960, a right nephrectomy was
performed, during which numerous fibrous
adhesions and an aberrant renal artery compressing the ureteropelvic junction were
encountered.
The weight of the kidney was 330 Gm.,
and its dimensions were 15 by 9 by 6.8 cm.
(Fig. 2, A and B). Dense scar tissue replaced
the capsule and most of the cortex. Areas of
suppuration and small and large semiconfluent yellow nodules replaced much of the
renal tissue. The dilated calyces and pelvis
had severely inflamed atrophic mucosa
and pericalyceal fibrosis.
Pathology
Although primarily involving the kidney
and destroying many of its normal markings,
the disease also extended to involve the
capsule and the immediate perirenal tissue
in all of the cases of this report (Fig. 3).
The remainder of the urinary tract was
spared. The extent of renal replacement was
variable, being diffuse and nodular and
sometimes suggestive of an abscess or neoplasm. Hydronephrosis, renal atrophy, and
fibrosis accompanied the foam cells, and in
some areas fibrosis was more prominent
than these cells. The cellular portions were
an admixture of large, uniform, mononuclear
cells with a reticulated and finely vacuolated
cytoplasm (Fig. 4) containing lipid and
inflammatory cells consisting of plasma cells,
polymorphonuclear leukocytes, and lymphocytes. The foam cells occasionally were
individual but generally occurred in small
groups, the latter sometimes having an
epithelial appearance (Fig. 5). Infrequently
they were distorted by inflammatory infiltrate and thus lost their epithelial pattern
and assumed a mesenchymal appearance
(Fig. 6). The nuclei, although they were
generally small and uniform and had a fine
reticulated chromatin that was devoid of
mitotic activity, occasionally wrere large
and simulated those of malignant cells.
June .1.968
XANTHOGRANULOMATOUS PYELONEPHRITIS
619
FIG. 2. Case 4. Capsular surface (upper) and internal structure {loiver) of kidney, with renal tissue
diffusely replaced by fibrous and xanthomatous nodules. Calyces and pelvis are dilated and their mucosal
surfaces are irregular.
620
Vol. 39
SAEED AND PINE
Three of the 4 cases contained areas of
poorly cellular fibrous tissue.
Special studies were performed by means
of a number of lipid and other stains, and the
results are tabulated in Table 1. Additional
fixation in formol calcium chloride, followed
by chromation and carbowax embedding,
was used for fat staining. A variety of lipids
was present in the vacuolated cells and was
best demonstrated by preheating the staining solution to 56 C. and staining at this
temperature. A greater quantity of lipid
was visualized by this method, and the
intensity of its color was greater than in
sections stained at room temperature.
Neutral fat and cholesterol esters predominated; phospholipids and cholesterol, on
the other hand, were very sparsely
distributed, and the latter was most infrequent. Unsaturated lipid, demonstrated
by means of the bromine-silver method,13
constituted only a small part of the total
lipid stained with other lipid stains.
A moderate amount of intra- and extracellular hemosiderin was present in 2 of the
4 cases.
Clinical Features
Age. The disease is most prevalent after
the third decade, having occurred at this
time in 26 of the 31 cases in the literature
and in all of the present group. Ages have
ranged from 17 to 77 years, but the greatest
number occur in the fifth decade: 13 from
the literature and 2 of the cases in the present
report.
Sex. Sex distribution has been even in our
cases, but men have been afflicted more
often among the previously reported cases
(18:13).
Races. Seventy-five per cent of the present
cases and 93 per cent of those reported in
the literature have occurred in Caucasians.
Site. There has been slight difference in
predilection of the kidney involved. The
right was afflicted in 3 of the present cases,
whereas the left was the seat of disease in
16 of the previously reported cases for which
such information is available. Bilateral
involvement has not been reported.
Signs and symptoms. Pain and tenderness
in the costovertebral angle or upper abdomen
was the most common complaint. Fever,
dysuria, and rarely a mass were presenting
features on fewer occasions.
Course and Therapy
Nephrectomy has been the mode of
therapy and has resulted in the relief of
symptoms, but follow-up information obtained over long periods of time is not available.
DISCUSSION
The etiology and origin of the lipid and
macrophages is inconclusive and seems to
revolve about 3 themes: bacterial infection
with subsequent tissue destruction and
liberation of lipids calling forth the histiocytic response; a metabolic defect with
secondary inflammatory infiltration; and
thirdly, a combination of these 2 plus other
factors, such as vascular insufficiency and
ureteral obstruction resulting from renal
calculi or strictures. The large numbers of
inflammatory cells would tend to incriminate
infection as the primary process, but this
hypothesis seems somewhat untenable in
view of the inconspicuous lipid macrophages
generally associated with pyelonephritis,
even when it is accompanied by abscesses.
The sparsity of lipid macrophages in pyelonephritis has been noted previously,15' 19, 20
and we were able to find them only infrequently in sections of 3 of 100 cases of pyelonephritis. If infection is the underlying
cause of the disease, the various members
of the Gram-negative group and staphylococcus that have been cultured would
suggest it is not the result of a specific
species of bacteria.
Metabolic defect is probably as realistic
an explanation if one considers the lipid
increase in the renal tubules of lipoid
nephrosis and the increase demonstrated by
Windaus26 in glomerulonephritis (0.22 to
0.33 mg. of free cholesterol and 0.09 to
0.65 mg. of esterified cholesterol per 100 Gra.
of kidney, as compared with 0.22 mg. of
free and 0.01 to 0.3 mg. of esterified in the
normal). Data regarding blood lipids are
not available; this aspect should be studied
in the future.
That impedance of urine flow owing to
' * & >
' & > • *
FIG. 3 {upper left). Case 3. Lipid-containing cells have extended to involve the perirenal fibrofatty
tissue. Hematoxylin and eosin. X 150.
FIG. 4 (upper right). Case 4. Masses of large cells with abundant vacuolated cytoplasm rich in lipid.
Inflammatory component is sparse. Hematoxylin and eosin. X 390.
FIG. 5 (lower left). Case 2. lieticulin fibers outlining individual and groups of cells. Wilder reticulin.
X 300.
FIG. 6 (lower right). Case 4. Lipid content of the cells is less apparent, and they have lost their epithelial appearance so that they simulate a mesenchymal growth. Inflammatory cells are prominent. Hematoxylin and eosin. X 390.
621
2+
4+
2+
1+
3
4
4+
4+
4+
4+
56 C.
2+
4+
4+
4+
PosiPositive
tive
Fine granules
about vacuoles of foam
cells
PosiPositive
tive
Fine granules
about vacuoles of foam
cells
Negative
Negative
4+
2+
§ Feigin method. 16
*[ l : 2 - N a p t h o q u i n o n e method. 1
|| Bromine-silver method. 1 3
Abundant,
pericellular, and
about
groups of
cells
Abundant,
pericellular, and
about
groups of
cells
Abundant,
pericellular, and
about
groups of
cells
4+
4+
PosiPositive
tive
Fine granules
about vacuoles of foam
cells
Wilder Reticulin
Negative
With
diastase
Abundant,
pericellular, and
about
groups of
cells
Without
diastase
PosiPositive
tive
Fine granules
about vacuoles of foam
cells
ZiehlNeelsen
GrocottBrownBrenn
Periodic acid-Schiff
reaction
Negative
Of unAfter
stained
glycerol digitonin
mounted reaction
section
Polarization
* Cain's method. 16
f Baker's acid hematin method for phospholipids. 7
| Fischler and Meyer-Brunot methods. 7
2+
2+
4+
2+
2
3+
2+
4+
2+
1
Room
temperature
56 C.
Room
temperature
Sudan Black B
Case
No.
Flaming Red
TABLE 1
Pink
Pink
Pink
Pink
Nile*
Blue
Sulfate
(0.02
and 1%)
STAINING R E A C T I O N S OF XANTHOGRANULOMATOUS
Positive
Very
sparsely
positive
Very
Positive
sparsely
positive
Very
Positive
sparsely
positive
Sparsely Nega- Negapositive tive
tive
Sparsely Nega- Negapositive tive
tive
Sparsely Nega- Negapositive tive
tive
Cholesterol U
and Its
Esters
Positive
Fattyt
Acid
Digitonin§
Alcohol-Ether
(Polarization)
Very
sparsely
positive
With
extract
Sparsely Nega- Negapositive
tive
tive
Without
pyridine
Phospholipids!
PYELONEPHRITIS
Without
bromine
(control)
Sparsely Negapositive tive
Sparsely Negapositive tive
Sparsely Negapositive tive
Sparsely Negapositive tive
With
bromine
Unsaturated Lipid[[
June 1963
623
XANTHOGRANULOMATOUS PYELONEPHRITIS
stricture, calculus, or aberrant blood vessels
may play a role in the pathogenesis of the
disease is suggested by its frequency in the
reported and present cases. Calculi were
present in 14 of the reported cases in which
information was given. If important, it
would be likely to be related to the concomitant infection that is so often associated
with urinary calculi. Vascular compromise
and lymph stasis have been suggested by
Osterlind16 as playing a role in the pathogenesis of the entity. Case 3 would tend to
support the importance of vascular impairment.
The source of the macrophages likewise
has been a point of conjecture. Reticuloendothelial origin17'21-24 seems most favored,
but tubular epithelial origin12 has been
TABLE 2
D I F F E R E N T I A L D I A G N O S I S OF XANTHOGRANULOMATOUS P Y E L O N E P H R I T I S
Xanthogranulomatous
Pyelonephritis
Renal Cell Carcinoma,
Clear Cell Type
Malacoplakia and
Histiocytoma
Diffuse nonencapsulated
nodules with varying
fibrosis and
hemorrhage frequently involving the pelvis and
calyces
Pleomorphic and abundant
Large with distinctly
vacuolated cytoplasm;
rarely clear
Usually a single unipolar and
sharply demarcated yellow
to amber mass; areas of
softening and hemorrhage
are common
Diffuse yellow to brownyellow tissue;
infrequent hemorrhages
Usually absent, b u t may be
present in necrotic areas
Large with clear or finely
granular eosinophilic cytoplasm; rarely vacuolated;
frequently tubular a r r a n g e ment
Sparse to moderate
Plconiorphism
Absent
Mitosis
Michael is-Gutman bodies
Periodic acidSchiff without,
diastase
Periodic acidSchilT after
diastase
Absent or very rare
Absent
Generally a p p a r e n t ; may be
uniform
Variable; may be very rare
Absent
Pi.eticulin
Abundant
and
often
around individual cells
Abundant, filling
the
vacuolated
macrophages
Extent, of involvement
Inflammatory
infiltrate
Cell size and
shape
-
Lipid
Retroperitoneal
involvement
Venous
inva-
sion
Metastasis
Vascularity
Prognosis
Finely positive granules
outlining vacuoles of
foam cells
Unchanged
Usually strongly positive in
cytoplasm of clear and
granular cells
Generally negative. Occasionally positive granules
in macrophages and tumor
cells
Mostly about groups of cells
Variable; principally in clear
tumor cells and vacuolated
macrophages
R a r e ; found only when tumor
bursts through the capsule
Large with granular eosinophilic
cytoplasm
t h a t may have occasional vacuoles containing R B C or hemosiderin, or both
Absent
Absent or rare
Present in malacoplakia
Positive in cytoplasm
Positive, unchanged
Mostly about groups of
cells
Generally absent; may be
rare fine positive cytoplasmic
granules
in
malacoplakia
Positive; negative
Common and confined to
immediate area of kidney
Negative
Frequent
Negative
Absent
Slight
Good
Frequently present
Generally a b u n d a n t
Poor
Absent
Slight
Good
624
Vol. 89
S A E E D AND F I N E
suggested on the basis of histologic similarity between cells lining the renal tubules
and the lipid-containing cells.
Even when all the clinical tests, including
x-ray visualization, are used, the clinical
diagnosis can not be made with any degree
of accuracy. Generally, neoplasm, cyst, and
hydronephrosis are diagnosed, and the true
nature of the condition is recognized only
after examination of the specimen. Pathologic diagnosis likewise presents difficulties,
inasmuch as both gross and microscopic
appearance may simulate other kidney
diseases, such as adenocarcinoma of the
kidney, particularly the clear cell type,
malacoplakia, and histiocytoma. Features
helpful in distinguishing these entities are
listed in Table 2. Data relating to the latter
diseases were derived from a study of 125
cases, 3 cases, and 1 case, respectively.
Biopsy of the retroperitoneal extension of
xanthogranulomatous pyelonephritis may
lead to an erroneous diagnosis of the lesion
described by Oberling14 as retroperitoneal
xanthogranuloma. Involvement of the kidney in the former condition or radiographic
alterations of the pelvis and calyceal system, or both, should serve as differential
diagnostic aids.
SUMMARY
Four cases featuring lipid-containing
cells involving the kidney are reported and
reviewed, together with 31 similar cases
previously reported. Problems in diagnosis
and differential diagnosis are discussed,
and the need for distinguishing this benign
condition from the clear cell renal adenocarcinoma, which it may closely resemble,
is stressed.
SUMMARIO I N I N T E R L I N G U A
Es reportate e revistate quatro casos de
pyelonephritis xanthogranulomatose, in que
cellulas a contento de lipido esseva incontrate in le renes. Es notate 31 simile casos
previemente reportate in le litteratura.
Problemas de diagnose e de diagnose differential es discutite. Es sublineate le necessitate de distinguer iste benigne condition ab
le adenocarcinoma renal a cellulas clar, con
le qual illo pote exhibir forte similitude.
Acknowledgments.
We wish to express our a p preciation to H . C. Stetfee, M . D . , for permitting
us to use Case 2, to M r . A. Bowden and M r . W.
Harlan for preparing t h e photographs, and to
Mrs. S. Lieth for, typing t h e manuscript.
REFERENCES
1. ADAMS, C. W . : A perchloric acid-naphthoquinone method for t h e histochemical localization of cholesterol. N a t u r e , London, 192:
331-332, 1961.
2. B A R R I B , H . J . : Foam-cell granuloma in chronic
pyonephrosis
simulating
tuberculosis.
Brit. J . Surg., 36: 316-319, 1949.
3. CANDIANI, A.: R a r a forma di granuloma renale
aspecifico simulante u n tumore maligno.
Acta chir. ital., 11:121-137, 1955.
4. CANGBLOSI, J . T . : Replacement lipomatosis resembling renal tumor. U. S. Armed Forces
M . J . , 4: 743-746, 1953.
5. F A R R O W , F . C , C R O S S , J . B . , T A N N H A U S E R , S.,
AND ANDREWS, J . T . : Renal lipomatosis.
New York J . Med., 49: 2924-2932, 1949.
6. G H O S H , H . : Chronic pyelonephritis with
xanthogranulomatous change: report of 3
cases. Am. J . Clin. P a t h . , 25: 1043-1049,
1955.
7. L I L L I B , R . D . : Histopathologic Technic a n d
Practical Histochemistry. New York: T h e
Blakiston Company, 1954, p p . 307-308 and
322-323.
8. M A C K , F . G., AND M A D O R , M . L . : Pyogenic
(foam cell) granuloma in a case of pyonephrosis. J . Urol., 67: 258-261,1952.
9. M A T H I S , R.
I.,
AND L O R E N Z O , J . :
Absceso
cortical de rinon simulando un neoplasma.
Rev. argent, urol., 14: 183-189, 1945.
10. M E L I C O W , M . M . : X a n t h i c lesions: report of
four cases, including two of " x a n t h o m a t o sis" of t h e kidney. J . A. M . A., 105: 768774, 1935.
11. M I T C H E L L , R. E . , J R . , D O D S O N , A. I., AND
K A Y , S.: X a n t h o g r a n u l o m a t o u s
pyelonephritis. Am. P r a c t . & Digest T r e a t . , 10:
2150-2155, 1959.
12. M O S T O P I , F . K . : Pyelonephritis with pseudoxanthomatous reaction. Penrose Cancer
Seminar, Case 5. Vol. 2 (1): 1956.
13. N O R T O N , W. T . , K O R B Y , S. R., AND B R O T Z , M . :
14.
15.
16.
17.
18.
19.
Histochemical demonstration of unsaturated lipids by a bromine-silver method. J .
Histochem., 10: 83-88, 1962.
OBERLING, C : Retroperitoneal xanthogranu.. loma. Am. J . Cancer, 23: 477-489, 1935.
0-STERLIND, S.: (jber Pyelonephritis xanthomatosa. Acta chir. scandinav., 90: 369-376,
1944.
P E A R S E , A. G. E . : Histochemistry. Theoretical
and Applied. Boston: Little, Brown &
Company, 1960, p p . 322-323 and 861.
P L B W E S , L. W . : N a t u r e and origin of t h e
xanthoma cell. Arch. P a t h . , 17: 177-186,
1934.
SCHLAGENHAUFER, F . : (jber cigentiimliclie
Staphylomykosen der Nieren und des pararenalen Bindegewebes. Frankfurt. Ztschr.
P a t h . , 19: 139-148, 1916.
SCHULTHEIS, T . : Histologische
Untersuchungen an Steinnieren. Ztschr. urol.
Chir., 3 1 : 193-230, 1931.
XANTHOGRANULOMATOUS PYELONEPHRITIS
June 1963
20. SCHULTHEIS, W.: Uber Stoffniederschliige und
Ablagerungen in den Wiinden der ableitenden
Harnwege. Ztschr. urol. Chir., 36: 16-27,
1932.
21. SELZER, D.
W.,
DAHLIN,
D.
C,
AND
DE
WEEBD, J. H.: Tumefactive xanthogranulomatous pyelonephritis. Surgery, 42: 274883, 1957.
22. SMITH, D. T.: Giant centrospheres in xanthomatous tumors. Bull. Johns Hopkins
Hosp., 33: 342-344, 1922.
23. STEWART, M. J.: On the cellular reactions in-
625
duced by local deposits of cholesterin in
tissues. J. Path. & Bact., 19: 305-314,1914.
24. STEWART, M. J.: Xanthoma and xanthosis.
Brit. M. J.,2:893-S96,1924.
25. STOUT, A. P.: Tumor seminar of the Texas
Society of Pathologists. Texas J. Med., 47:
568-569, 1951,
26. WINDAUS, A.: Uber die quantitative Bestimmung des Cholesterins und der Cholesterinester in einigen normalen und pathologischen Nieren. Ztschr. physiol. Chem., 65:
110-117, 1910.