Case Discussion <Brief History> A 14 year-old girl was admitted for recurrent fever, chills and right flank pain one month prior to this admission. This girl was well except that two episodes of UTI and hematuria were noticed when 1 and 3 year-old, but her mother did not recall any specific abnormality was told at that time. She also denied sexual exposure history. She presented fever up to 38.5℃, chills, dysuria, and right flank pain developed two weeks ago. Physical examination showed right costovertebral angle tenderness. Initial laboratory included complete blood count (WBC: 13.2 x 103 ), urinalysis (20-40 WBC and 10-20 RBC), blood culture and urine culture were done when she was sent to a local hospital. The symptoms persisted after antibiotics were given (1st generation Cephalosporin + gentamycin). However, her condition did not improved even deteriorated after one-week treatment, and she was asked to transfer to our ER. Acute pyelonephritis, DIC and impending septic shock were impressed, and fluid challenge, inotropic agent and strong antibiotics were given immediately. Fever subsided gradually in 5 days. She was discharged after another 10 days treatment. Unfortunately, fever relapsed 3 days after discharge. She was sent to our hospital again. Mild right hydronephrosis was disclosed in the renal sonography. Urine culture yielded E.coli. Prolonged antibiotics treatment was given for 3 weeks. During the hospitalization, she underwent a radionuclide -DMSA scintigraphy for renal involvement (Fig. 1 ) and a radionuclide cystography (RNC) detection of vesicoureteral reflux (Fig 2. ) after her condition was stable. Prolonged antibiotics prophylaxis was suggested after discharge. Fig. 1 Technetium-99m DMSA scan showed generalized decreased uptake with loss of volume of the right kidney, and left kidney was normal. Pyelonephritis or scarring was impressed. The differential cortical uptake was 78.5% by the left kidney and 21.5% by the right kidney. Fig 2. A radionuclide cystogram (RNC) showed grade 2 vesicoureteral reflux (right). <Discussion> In the preantibiotic era, UTI was a serious disease with significant mortality. In the modern era there is still, however, a nonnegligible degree of long term consequences. Of children entering dialysis, 10 to 20 % have a history of UTI or reflux, or both. There are a number of approaches for the diagnostic imaging evaluation of UTI. It is now well-accepted that all children with the first UTI should be evaluated for predisposing factors. The risk factors for the development of scarring related to UTI include (1) obstruction, (2) reflux, (3) young age, (4) delay in treatment, (5) number of pyelonephritis attacks, and (6) unusual bacteria. Technetium-99m DMSA scintigraphy is superior to sonography and to intravenous pyelography (IVP) for the detection of acute pyelonephritis or scar, or both. The number of defects detected on DMSA scintigraphy with repeated episodes of pyelonephritis may increase over time as scarring replaces the renal parenchyma. It has been reported that DMSA has a sensitivity of 96% and a specificity of 98% for the detection of changes induced by pyelonephritis. Vesicoureteral reflex is the most significant host risk factor for the development of UTI and renal scarring. The radionuclide cystogram RNC is indicated for children diagnosed with UTI for the evaluation of genitourinary reflux. Three degrees of reflux can be recognized with RNC. Grade 1 corresponds to reflux to ureter. Grade 2 corresponds to reflux into the ureter reaching the pelvis that do not appear dilate, and Grade 3 corresponds to reflux reaching a dilated pelvis, with or without dilated and tortuous ureter. There is a correlation between grade of reflux and the severity of scarring detected by DMSA scan. Higher grades of reflux lead to greater severity of abnormality seen on DMSA scan. 繼續教育考題 1. (A) Which of the following statement regarding to UTI in children is NOT TRUE? A UTI occurs in as many as 5% of male and 1-2% of female children, B Vesicoureteral reflux is the most common abnormality, C Premature infants, children with systemic or immunologic diseases, urinary tract abnormality are high risk groups, D Girls younger than 5 years with a previous history of UTI should be evaluated for the underlying etiology. 2. (D) Which of the following statement regarding to UTI in children is TRUE? A Etiology is essentially the same as in adults, with 80% due to E. coli, B Patients with recurrent infections or underlying structural abnormalities are more likely to demonstrate other pathogens over time (such as Klebsiella, Pseudomonas spp.), C Bacteriuria in neonates and infants, and in boys beyond infancy, is associated with a high incidence of urinary tract abnormalities and necessitated prompt diagnosis and early treatment. D All of the above 3. (E) Which of the following statement regarding to indications of radiographic study in UTI in children is TRUE? A  Any male or female child younger than 5 years with asymptomatic UTI or bacteriuria, B Any male child with a first episode of UTI or asymptomatic bacteriuria, C Recurrent UTI in female children, and any children with pyelonephritis, D A children with first UTI and a family history of UTI. E All of the above 4. (B) Which of the following statement regarding to radiographic study in UTI in children is NOT TRUE? A Voiding cystourethrography (VCUG) will detect VU reflux and provide anatomic and functional information of lower urinary tract, B Direct radionuclide voiding cystography will detect reflux with increased gondal radiation when compared to VCUG, C  Tc-99m DTPA provides glomerular filtration and excretory function, and when combined furosemide, it could be differentiated the mechanical or non-mechanical obstruction of hydronephrosis, D Tc-99m DMSA accumulates in functional renal cortex and is useful in demonstrating acute pyelonephritis and evaluating focal parenchymal scarring. 5. (A) Which of the following statement regarding to approach to UTI in children is NOT TRUE? A Renal sonography can reveal anatomic information, and most of time it is sufficient to make the correct diagnosis, B Immediate renal sonography can be done in the acutely ill child to exclude the obstruction, C Transient reflux can be masked or overestimated during an acute UTI, therefore the optimal timing of VCUG is debated, however, it is reasonable to conduct during the initial hospital administration, D Mild to moderate reflux might disappear with increasing age. Follow-up studies are indicated. 6. (C) Which of the following statement regarding to sequelae of UTI in children is NOT TRUE? A As many as 80% of children will recur, B Parenchymal scarring is found in 10-15% of children with UTIs, C Patients with mild to moderate VU reflux should receive surgical intervention when recurrent UTIs, D Continuous use of prophylactic antibiotics is suggested in children with structural abnormalities, especially VU reflux. 7. (B) Which of the following statement regarding to diagnosis of UTIs NOT TRUE? A Renal abscesses present with identical signs and symptoms to pyelonephritis, and should be considered if fever persists beyond 48-72 hours despite appropriate antibiotics, B Hematuria is uncommon in acute cystitis in women, C 30-40% of patients with acute pyelonephritis will have positive blood cultures. D  In older man, persistent or recurrent bacteriuria is associated with prostate enlargement or chronic prostatitis. 8. (A) Which of the following statement regarding to treatment of UTIs is NOT TRUE? A Asymptomatic bacteriuria in diabetes without anatomic abnormalities is not indicated to antibiotic treatment, B  Pregnant women should be screened for presence of bacteriuria, and should be treated. C  In pyelonephritis, total of 14 days treatment are usually given, D Painless complicated pyelonephritis can be observed in diabetics, renal transplant patients and alcoholics 9. (E) Which of the following statement regarding to catheter- associated UTI is TRUE? A The most common nosocomial infection, B With long-term catheterization (>30 days), many patients have at least two bacterial strains, C Asymptomatic colonization and symptomatic infection is difficult to differentiate, however, pyuria accompanies most of symptomatic infection, D Asymptomatic bacteriuria should not routinely be treated. E  All of the above. 10. (D) Which of the following statement in UTIs is FALSE? A When fever is present in a child, the diagnosis of UTI should routinely be considered, B Prolonged fever in patients with acute pyelonephritis, atypical pathogens (such as TB, sexual transmitted disease) or complications (such as abscesses) should be considered, C E.coli is the most common pathogen, D In elderly, pyuria always accompanies with bacteriuria. 答案解說 (A) UTI occurs in as many as 5% of female and 1-2% of male children (D )  (E )  (B ) Direct radionuclide voiding cystography will detect reflux with decrease gondal radiation 50 to 100-fold when compared to VCUG. (A) Renal sonography must be combined with a functional study (e.g., special scans) for the detection or underlying abnormalities. (C)  Mild to moderate reflux will resolve spontaneously with the growth, and adequate antibiotics prophylaxis should be given. Overall, 70% of patients with VU reflux that is managed conservatively, the condition resolves spontaneously. (B)  Hematuria is not uncommon, 50% women with acute cystitis have hematuria. However, it is uncommon in vaginitis or urethritis. (A) Asymptomatic bacteriuria in diabetes (especially in women) should be treated due to frequency of upper UTIs when bacteriuria is present. On the other hand, the risk of pyelonephritis and subsequent stillbirth or prematurity, asymptomatic bacteriuria in pregnant women should be treated. (E)  (D)  Unlike younger people, in the elderly the presence of pyuria does not correlate highly with bacteriuria. But absence of pyuria is a good indicator of the absence of bacteriuria.