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Urinary and Genital Disorders (Children)

Recurrent uti(?), pyuria

10/16/2007

Question:

My son is 4 yrs. old. He is suffering from recurrent fever since 01.08.2007. the case is as follows:

01.08.2007--- High fever. antibiotic cefoprox was given, Afebrile in 2-3 days.

05.08.2007---- Infectious hepatitis was diagnosed. (urine routine –NAD), (SGPT 1119), total bilirubin 1.3, indirect bilirubin 0.6 ,direct bilirubin 0.7) , HBsAG—Negative Complain of abdominal pain and itching at penis and nearby area

13.08.2007--- again high fever (103 F), cefixime was given , afebrile in 2-3 days.

20.08.2007---- again high fever (103 F), admitted indoor 1. Urine exam(20.08.2007)---- Albumin +, pus cell—full field, epith. Cell +, RBC--- full field , bacteria +++, occult blood + 2. CBC(20.08.2007) ----- TLC 23800, RBC 4.72x106 mm3 , platlet 733000 mm3 , pct .592, mcv 77f1, mch 26.1 pg, DIFF. lym 22.5%, mon 4.7%, gra 72.8% , eosino by slide 1%. (Leukemoid reaction) 3. MPqbc & widal (20.08.2007)--- Negative 4. USG(20.08.2007)---- liver enlarged 13.89x4.9cm, spleen –8.2cm, kidney 8.09x2.74 cm, 9.65x3.98 cm. no other abnormality. 5. Urine culture---(24.08.2007 & 25.08.2007) both sterile(was on antibiotic but not responding) 6. blood culture---(24.08.2007 & 25.08.2007) one sterile and other staphylococcus aureus 7. ECHO Cardiography (28.08.2007)------mid AR, no vegetations seen.( my son had by birth mild AR and bicuspid aortic valve. 8. BCG given on 25.08.2007 ---No exaggerated reaction.

treatment given indoor • ceftriaxone+garamycin ----- 5 days then • cefepime+ tazobactum and amikacin for 7 days • chloroquin phosphate --- 3days

Discharged from hospital in good active and afebrile condition.

05.09.2007---- a short spike in temp 99.80 F. 11.09.2007--- high fever with chill (103 F), with two episodes of vomiting, admitted indoor

• Urine exam(11.09.2007)---- Albumin +, pus cell—full field, epith. Cell +, bacteria +, mucus present • CBC(11.09.2007) ----- TLC 26300, RBC 3.90x106 mm3 , platlet 503000 mm3 , pct .406, mcv 77f1, mch 26.1 pg, DIFF. lym 11.5%, mon 2.2%, gra 86.8% , eosino by slide 1%. (Leukemoid reaction) • MPqbc & widal (11.09.2007)--- Negative

• USG(15.09.2007)---- Kidneys enlarged—Right 9.2x2.9 cm with cortical thickness 6mm. left 9.0x3.6 cm with cortical thickness 7mm. The cortical echoes of both the kidneys are bright and inhomogeneous (Gr.1).( Pre void volume 115ml, post void 10ml) Mild hepatosplenomegaly . no other abnormality.

• Urine culture---(12.09.2007)---sterile(antibiotic stopped since 06.09.2007 again started on 11.09.2007 night) • Urine culture( 15.09.2007)-- sterile(was on antibiotic )

• CBC(22.09.2007) ----- TLC 8000, poly 52%, lym 39%, eosino 4%, mono 5%, baso 0%

• Urine exam(22.09.2007)---- Albumin- nil, pus cell—2-4, epith. Cell –few , mucus present

treatment given indoor • cefepime+ tazobactum for 14days • gentamycin --- 7days • linezolid (oral) for 14 days

Discharged from hospital in good active and afebrile condition.

I went to higher centre with my son on oral Linezolid for further consultation. There few tests were done---

25.09.2007 • ESR (westergren) -76mm/1st hr • Anti Streptolysin ‘O’ – NEGATIVE • ECHO CARDIOGRAPHY --- no vegetations seen • DMSA RENAL SCAN --- Left enlarged kidney with adequate cortical function with no evidence of scarring . Right normal sized kidney with mildly impaired cortical function with scarring(?) at both poles. Diff. function left 62% and Right kidney 38%.

Suggested for MCUG after at least two weeks.

He was on continuous linezolid(oral) and cefixime(oral) for 2 weeks more, in between few exam were done.

1. Urine exam(02.10.2007)---- Albumin -nil, pus cell—0-2, epith. Cell moderate, RBC--- nil , bacteria ++, cast –nil, mucus—present

2. Urine exam(09.10.2007)---- Albumin -trace, pus cell—20-25, epith. Cell few, RBC--- occasional , bacteria +, cast –co.gr.castes 0-2/lpf, mucus—present 3. Urine exam(11.10.2007)---- Albumin -trace, pus cell—15-20, epith. Cell few, RBC--- nil , bacteria ++, cast –occasional granular, mucus—present 4. Blood sugar(fasting)(10.10.2007)---75mg/dl

5. ESR(10.10.2007)—20mm after1hr

6. CBC(10.10.2007) ----- TLC 9600, RBC 4.90x106 mm3 , platlet 472000 mm3 , Hb 11, hct 36, mcv 73.8f1, mch 24.1 pg, DIFF. lym 52.2%, mxd 13.1%, neut 34.7% , eosino by slide 4%.

7. Urine gram stain(10.10.2007)---ocassional gram positive cocci seen

8. Urine AFB stain(10.10.2007)---negative 9. Urine culture(10.10.2007)----COAGULASE NEGATIVE STAPHYLOCOCCUS SP.(sensitive with linezolid, cotrimoxazole, gentamicin, roxytromycin)(antibiotic stopped from 09.10.2007)

10. Urine culture(11.10.2007)----budding yeast grown)(antibiotic stopped from 09.10.2007) 11.

He is presently on oral cotrimoxazole since11.10.2007night .This time he is getting pus cells and casts in urine but not having fever.

My questions are :

1. Is it a case of definite recurrent UTI? 2. Routine urine test of my son in these 2 months is performed 8-10 times. Mucus is always present in all samples even in good afebrile condition. What may be the reason for it? And what is the treatment? 3. In afebrile condition he is active, alert having good appetite. can he have a serious disease? 4. Should I go for MCUG test even if he is getting pus cells in urine? PLEASE HELP ME.

Answer:

Thank you for your question. On this site, we try to answer general questions about children's urinary and genital disorders. You appear to have some very, very specific questions about your child, which can only be answered properly by a physician who is familiar with your child's history, physical exam, and test results. Your questions about testing results and the risks, benefits, and alternatives for any treatments need to be directed to your treating physician(s). You should insist that they answer these questions in a way that you are able to understand before you consent to any treatment. If your physician is unable to help you understand these issues, you should get a second opinion. Good luck!

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Response by:

Jack S Elder, MD, FACS, FAAP Jack S Elder, MD, FACS, FAAP
Clinical Professor of Urology
School of Medicine
Case Western Reserve University