Management Challenges of Bilateral Xanthogranulomatous Pyelonephritis in a Patient With End-Stage Renal Disease in a Low-Resource Setting: A Case Report.

Xanthogranulomatous pyelonephritis (XGP) is a rare, chronic, and destructive renal inflammatory disease that often mimics renal malignancy, presenting significant diagnostic challenges, particularly in patients with end-stage renal disease (ESRD). We report a 55-year-old African man with diabetes mellitus, hypertension, and ESRD on hemodialysis who presented with progressive dyspnea and fluid overload. Imaging revealed bilateral heterogeneous renal masses highly suggestive of renal cell carcinoma; however, limited diagnostic resources and his unstable condition precluded advanced imaging or early tissue sampling. Histopathological examination later confirmed XGP, showing diffuse infiltration by lipid-laden macrophages, chronic inflammatory cells, and multinucleated giant cells. The patient deteriorated and died before results became available. This case highlights the difficulty of distinguishing XGP from renal malignancy in resource-constrained settings, underscores the importance of early histopathological evaluation where feasible, and emphasizes the need for heightened clinical awareness to avoid misdiagnosis and delays in appropriate management.