Soo Jin Jung, et al: Malakoplakia of the Kidney in a Patient with Secondary Adrenal Insufficiency from an interaction between various factors such as bacterial infection, impaired host immune response and diminished leukocyte function under the influence of a systemic illness such as secondary adrenal insufficiency and diabetes mellitus. The common presenting features of malakoplakia of the kidney are high fever, loin tenderness, and a palpable mass with a history of urinary tract infection.8) Based on the reported studies, the degree of decreased kidney function varies up to acute renal failure.12,13) Ultrasound and CT features are variable and only briefly mentioned in many reviews. Features include enlarged kidneys,14) focal hypoechoic renal masses that simulate abscesses15) and heterogeneous masses that calcify, show central areas of necrosis and are mistaken for tumors.16) The imaging appearance of malakoplakia is therefore non-specific, and malignant renal tumor is a common misdiagnosis. The final diagnosis of malakoplakia is usually attained only upon histopathologic examination of the excised specimen. There is no established treatment for patients with mala- koplakia. However, there are treatment options for malakoplakia that include antibiotics, surgical excision, or a combination of both, depending on the site and extent of involvement. Some researchers have suggested that such antibiotics as trimethoprim- sulfamethoxazole and ciprofloxacin were beneficial because of their ability to penetrate intracellularly.8,17-20) We started the treatment with ciprofloxacin. During follow-up in the outpatient clinic, we changed the antibiotic treatment to trimethoprim- sulfamethoxazole due to the patient’s continued complaint of cystitis symptoms. In conclusion, renal malakoplakia should be taken into account in the differential diagnosis of a patient who presents with urinary tract infection, fever, abdominal pain, and abscess- like lesion in ultrasonography or CT, especially if the patient concerned has diabetes mellitus and a long history of use of exogenous steroids. It is considered that family physicians’ early diagnosis would enable prompt treatment and regular monitoring, leading to avoidance of long-term morbidity and mortality. REFERENCES 1. Hamodat M, Naghibi B, Yousef GM. Malakoplakia of the neck in a patient with cancer of the colon. Can J Surg 2009;52:E107-8. 2. Kobayashi A, Utsunomiya Y, Kono M, Ito Y, Yamamoto I, Osaka N, et al. Malakoplakia of the kidney. Am J Kidney Dis 2008;51:326-30. 3. Mannan AA, Kahvic M, Singh NG, Abu Sara Y, Bharati C. An unusual case of extensive epididymotesticular malakoplakia in a diabetic patient. Int Urol Nephrol 2010;42:569-73. 4. Michaelis L, Gutmann C. Uber einschlusse in blasentumoren. Z Klin Med 1902;47:208-15. 5. Shabtai M, Anaise D, Frei L, Waltzer WC, Frischer ZI, Jao S, et al. Malakoplakia in renal transplantation: an expression of altered tissue reactivity under immunosuppression. Transplant Proc 1989;21:3725-7. 6. van Crevel R, Curfs J, van der Ven AJ, Assmann K, Meis JF, van der Meer JW. Functional and morphological monocyte abnormalities in a patient with malakoplakia. Am J Med 1998;105:74-7. 7. Hong JJ, Liao PL, Lin JL, Hsueh S, Huang CC. Bilateral renal parenchymal malakoplakia presenting as haemolytic-uraemic syndrome. Nephrol Dial Transplant 1999;14:2206-9. 8. Dobyan DC, Truong LD, Eknoyan G. Renal malacoplakia reappraised. Am J Kidney Dis 1993;22:243-52. 9. Dhabalia JV, Nelivigi GG, Jain NK, Suryavanshi M, Kakkattil S. Malakoplakia of the ureter: an unusual case. Indian J Urol 2008;24:261-2. 10. Jefferies WM. Cortisol and immunity. Med Hypotheses 1991;34:198-208. 11. Yousef GM, Naghibi B, Hamodat MM. Malakoplakia outside the urinary tract. Arch Pathol Lab Med 2007;131:297-300. 12. Albitar S, Genin R, Fen-Chong M, Schohn D, Riviere JP, Serveaux MO, et al. The febrile patient presenting with acute renal failure and enlarged kidneys: another mode of presentation of malakoplakia. Nephrol Dial Transplant 1997;12:1724-6. 13. Tam VK, Kung WH, Li R, Chan KW. Renal parenchymal malacoplakia: a rare cause of ARF with a review of recent literature. Am J Kidney Dis 2003;41:E13-7. Korean J Fam Med Vol. 32, No. 6 Sep 2011 | 371