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Jornal Brasileiro de Nefrologia 2022Xanthogranulomatous pyelonephritis consists of a chronic infectious and inflammatory process of the renal parenchyma, a variant of chronic obstructive pyelonephritis. It...
INTRODUCTION
Xanthogranulomatous pyelonephritis consists of a chronic infectious and inflammatory process of the renal parenchyma, a variant of chronic obstructive pyelonephritis. It is more prevalent in middle-aged adults, rare in pediatric patients, with less than 300 cases reported in children worldwide.
REPORT
Preschooler, aged 2 years and 11 months, male, with 2 months of abdominal distention, increased temperature and intense pallor, associated with microcytic anemia refractory to the use of ferrous sulfate. 1 week before, he had a bulging in his left flank and a hard palpable mass there. Imaging exams (ultrasound and tomography) revealed an overall enlargement of the left kidney, destruction of the renal parenchyma and intense calyceal dilation, forming the "bear's paw" sign, with a staghorn calculus in the pelvis. He underwent treatment with antibiotic therapy and total nephrectomy, with a specimen sent for pathological examination.
DISCUSSION
a disease of uncertain incidence in the pediatric age group, xanthogranulomatous pyelonephritis is more prevalent in male children and affects mainly the left kidney, being frequently associated with the presence of stones. Clinically, it has nonspecific symptoms, the most common being abdominal distension and asthenia. Laboratory exams shows microcytic, leukocytosis, thrombocytosis and increased inflammation, pyuria, hematuria and proteinuria, in addition to bacterial growth in urine culture. The diagnosis is anatomopathological, but it can be hinted by contrasted CT scan, with the classical sign of the "bear's paw". Treatment may include nephrectomy and broad-spectrum antibiotic therapy.
Topics: Adult; Animals; Anti-Bacterial Agents; Child; Humans; Kidney; Male; Middle Aged; Nephrectomy; Pyelonephritis, Xanthogranulomatous; Ursidae
PubMed: 33877258
DOI: 10.1590/2175-8239-JBN-2020-0246 -
The Western Journal of Emergency... Jul 2019Routine interventions in the practice of medicine often lack definitive evidence or are based on evidence that is either not high quality or of only modest-to-marginal... (Review)
Review
INTRODUCTION
Routine interventions in the practice of medicine often lack definitive evidence or are based on evidence that is either not high quality or of only modest-to-marginal effect sizes. An abnormal urinalysis in an elderly patient presenting to the emergency department (ED) with non-specific symptoms represents one condition that requires an evidence-informed approach to diagnosis and management of either asymptomatic bacteriuria or urinary tract infection (UTI). The emergency provider often will not have access to urine cultures, and the risks associated with antibiotic use in the elderly are not without potentially significant side effects.
METHODS
We performed a historical and clinical review of the growing body of literature suggesting measurable differences in the systemic immune response manifest among patients with asymptomatic pyuria and UTI, including increases in the pro-inflammatory cytokine interleukin-6 and the acute phase reactant procalcitonin.
RESULTS
Serum procalcitonin, a peptide that undergoes proteolysis into calcitonin, has been demonstrated to quickly and reliably rise in patients with severe bacterial infections, and may serve as a potentially sensitive and specific marker for identification of bacterial illness.
CONCLUSION
In the absence of validated risk scores for diagnosing UTI in elderly patients presenting to the ED, there may be a role for the use of procalcitonin in this patient population.
Topics: Aged; Asymptomatic Diseases; Bacteriuria; Biomarkers; Emergency Service, Hospital; Humans; Procalcitonin; Urinary Tract Infections
PubMed: 31316695
DOI: 10.5811/westjem.2019.5.42096 -
Journal of Yeungnam Medical Science Jan 2022The current guidelines for the diagnosis of acute pyelonephritis (APN) recommend that APN be diagnosed based on the clinical features and the presence of pyuria....
BACKGRUOUND
The current guidelines for the diagnosis of acute pyelonephritis (APN) recommend that APN be diagnosed based on the clinical features and the presence of pyuria. However, we observed that some of the patients who are diagnosed with APN do not have characteristic clinical features or pyuria at the initial examination. We performed this study to investigate the characteristics of APN without pyuria.
METHODS
A retrospective, cross-sectional study was conducted on 391 patients diagnosed with APN based on clinical and radiologic findings, between 2015 and 2019. The clinical features, laboratory results, and computed tomography (CT) findings were compared between patients with normal white blood cell (WBC) counts and those with abnormal WBC counts (WBC of 0-5/high power field [HPF] vs. >5/HPF) in urine.
RESULTS
More than 50% of patients with APN had no typical urinary tract symptoms and one-third of them had no costovertebral angle (CVA) tenderness. Eighty-eight patients (22.5%) had normal WBC counts (0-5/HPF) on urine microscopy. There was a negative correlation between pyuria (WBC of >5/HPF) and previous antibiotic use (odds ratio, 0.249; 95% confidence interval, 0.140-0.441; p<0.001), and the probability of pyuria was reduced by 75.1% in patients who took antibiotics before visiting the emergency room.
CONCLUSION
The diagnosis of APN should not be overlooked even if there are no typical clinical features, or urine microscopic examination is normal. If a patient has already taken antibiotics at the time of diagnosis, imaging studies such as CT should be performed more actively, regardless of the urinalysis results.
PubMed: 34411474
DOI: 10.12701/yujm.2021.01207 -
Kidney360 Mar 2022Autosomal dominant polycystic kidney disease (ADPKD) has phenotypic variability only partially explained by established biomarkers that do not readily assess...
BACKGROUND
Autosomal dominant polycystic kidney disease (ADPKD) has phenotypic variability only partially explained by established biomarkers that do not readily assess pathologically important factors of inflammation and kidney fibrosis. We evaluated asymptomatic pyuria (AP), a surrogate marker of inflammation, as a biomarker for disease progression.
METHODS
We performed a retrospective cohort study of adult patients with ADPKD. Patients were divided into AP and no pyuria (NP) groups. We evaluated the effect of pyuria on kidney function and kidney volume. Longitudinal models evaluating kidney function and kidney volume rate of change with respect to incidences of AP were created.
RESULTS
There were 687 included patients (347 AP, 340 NP). The AP group had more women (65% versus 49%). Median ages at kidney failure were 86 and 80 years in the NP and AP groups (log rank, =0.49), respectively, for patients in Mayo Imaging Class (MIC) 1A-1B as compared with 59 and 55 years for patients in MIC 1C-1D-1E (log rank, =0.02), respectively. Compared with the NP group, the rate of kidney function (ml/min per 1.73 m per year) decline shifted significantly after detection of AP in the models, including all patients (-1.48; <0.001), patients in MIC 1A-1B (-1.79; <0.001), patients in MIC 1C-1D-1E (-1.18; <0.001), and patients with (-1.04; <0.001). Models evaluating kidney volume rate of growth showed no change after incidence of AP as compared with the NP group.
CONCLUSIONS
AP is associated with kidney failure and faster kidney function decline irrespective of the ADPKD gene, cystic burden, and cystic growth. These results support AP as an enriching prognostic biomarker for the rate of disease progression.
Topics: Adult; Biomarkers; Disease Progression; Female; Glomerular Filtration Rate; Humans; Inflammation; Kidney Failure, Chronic; Polycystic Kidney, Autosomal Dominant; Prognosis; Pyuria; Retrospective Studies
PubMed: 35582184
DOI: 10.34067/KID.0004292021 -
Journal of Personalized Medicine Aug 2021Chronic kidney disease (CKD) is considered a major health problem, which poses a burden for health care systems worldwide. It has been estimated that 10% of the...
Chronic kidney disease (CKD) is considered a major health problem, which poses a burden for health care systems worldwide. It has been estimated that 10% of the population worldwide have CKD; however, most of the cases are undiagnosed. If left untreated, CKD could lead to kidney failure, which highlights the importance of early diagnosis and treatment. Pyuria has been reported in CKD patients, and could be the result of several comorbidities, such as diabetes, or urinary tract infections (UTIs). A few studies have shown that pyuria is associated with the late stages of CKD. However, there are limited data on the prevalence of non-UTI (sterile) and UTI-pyuria in different CKD patient populations, and its association with the decline in kidney function and progression of CKD. In this retrospective study, we report the prevalence of pyuria (sterile and UTI) in 754 CKD patients of King Fahd Specialist Hospital, Buraydah, Saudi Arabia. Our data showed that 164/754 CKD patients (21.8%) had pyuria, whereas 590 patients (78.2%) presented with no pyuria. There was a significantly higher percentage of late-stage (stage 4) CKD patients in the pyuric group compared to the non-pyuric group (36.6% vs. 11.9%). In line with the previous data, proteinuria was detected in a significantly higher percentage of pyuric patients, in addition to significantly higher levels of serum creatinine and urea, compared to non-pyuric patients. Furthermore, 13.4% of the pyuric CKD patients had UTI, whereas 86.6% presented with sterile pyuria. was indicated as the causative agent in 45.5% of UTI patients. Our patient data analysis showed that a significantly higher percentage of UTI-pyuric CKD patients, than sterile pyuric patients (63.6% vs. 19.7%), had higher numbers of urinary white blood cells (>50/HPF, WBCs). The data also showed that a higher percentage of UTI-pyuric patients were late-stage CKD patients, compared to sterile pyuric patients (50% vs. 34.5%). Our findings indicate that a high level of pyuria could be considered as a marker for late-stage CKD, and that UTI is an important risk factor for the decline in kidney function and the progression to late-stage CKD. We believe that further studies are needed to correlate pyuria to kidney function, which could be helpful in monitoring the progression of CKD. Moreover, the management of comorbidities, such as diabetes and UTIs, which are risk factors for CKD and associated pyuria, could help to control the progression of CKD to the late stages.
PubMed: 34575608
DOI: 10.3390/jpm11090831 -
Annals of Coloproctology Jul 2021Meckel diverticulum is a common congenital malformation of the gastrointestinal tract and can cause complications such as ulceration, hemorrhage, intussusception, and...
Meckel diverticulum is a common congenital malformation of the gastrointestinal tract and can cause complications such as ulceration, hemorrhage, intussusception, and perforation. This report describes a very rare complication of an enterovesical fistula associated with chronic Meckel diverticulum. A 51-year-old male presented with over 10 years of persistent pyuria. Tests were performed to rule out malignancy, including serum prostate-specific antigen level, urine cytology, bacterial culture, cystoscopy, and bladder computed tomography. An enterovesical fistula was identified, and laparoscopic exploration was performed. The findings suggested enterovesical fistula formation caused by chronic inflammation at the tip of a Meckel diverticulum. Segmental resection of the small bowel including the diverticulum and primary repair of the urinary bladder along with partial cystectomy were performed. The postoperative clinical course was uneventful. An enterovesical fistula is a very rare complication resulting from chronic inflammation of a Meckel diverticulum.
PubMed: 32178494
DOI: 10.3393/ac.2019.01.18 -
BJUI Compass Jul 2022To evaluate the role of a urine dipstick in the assessment of acute scrotal pain emergency department presentations.
OBJECTIVE
To evaluate the role of a urine dipstick in the assessment of acute scrotal pain emergency department presentations.
METHODS
A single institution, prospective case series, from February 2020 to February 2021. All patients who received a bedside review by a urology doctor for acute scrotal pain were included. Urine dipstick results were pre-defined as having had an impact on the emergency clinician's diagnosis if it showed pyuria and/or nitrituria and the final diagnosis was epididymitis-orchitis or haematuria and the final diagnosis was ureterolithiasis.
RESULTS
139 patients presented to the emergency department with a complaint of acute scrotal pain. 85 (61%) were referred for bedside urology review. Median age of 17 years (P25 12 yrs, P75 31 yrs). 2.3% ( = 2) had proven testicular torsion, 28.5% ( = 24) had epididymitis-orchitis and 8.2% ( = 7) had ureterolithiasis. 68 (80%) of patients received a primary diagnosis of testicular torsion by the emergency department clinician. Following review by a urology unit doctor, 14 proceeded to scrotal exploration for concern of testicular torsion. 7 patients were diagnosed with ureterolithiasis, all of whom had haematuria on their urine dipsticks (100%, 95% CI: 59-100%), 100% of these urine dipsticks were initiated by the urology unit doctor following bedside review. 22 patients were diagnosed with epididymitis-orchitis. 8 of these had pyuria, nitrituria and/or haematuria on their urine dipstick (36%, 95% CI: 17-59%) and only one urine dipstick was completed prior to referral. 20.6% of patients perceived to have testicular torsion by the emergency department had a positive urine dipstick that aligned with their final alternative diagnosis (95% CI: 12-32%).
CONCLUSION
A collection of clinical findings is required to diagnose the aetiology of acute scrotal pain. Information that can be easily, quickly, cheaply, and reliably collected, such as a urine dipstick, can assist in clinical decision making.
PubMed: 35783592
DOI: 10.1002/bco2.138 -
Australian Journal of General Practice Apr 2021Recurrent urinary tract infections (rUTIs) and recurrent cystitis symptoms without infection occur commonly in women and present frequently in general practice.
BACKGROUND
Recurrent urinary tract infections (rUTIs) and recurrent cystitis symptoms without infection occur commonly in women and present frequently in general practice.
OBJECTIVE
The aim of this article is to provide a management approach to the assessment and treatment of recurrent cystitis symptoms in women with rUTIs as well as women who have negative urine cultures.
DISCUSSION
Five common clinical scenarios are discussed with different approaches to treatment: true rUTIs with positive urine cultures, women with variable urine cultures (some positive and some negative), women with negative urine cultures who have pyuria +/- haematuria, women with completely normal urine cultures and women with ongoing symptoms after a definite UTI. Red flags signalling the need for early referral to a urologist for further assessment are discussed. Both non-antibiotic and antibiotic-related strategies to treat women with rUTIs are available.
Topics: Anti-Bacterial Agents; Cystitis; Female; Humans; Recurrence; Urinalysis; Urinary Tract Infections
PubMed: 33786541
DOI: 10.31128/AJGP-11-20-5728 -
Infection Control and Hospital... Feb 2023Clinicians and laboratories routinely use urinalysis (UA) parameters to determine whether antimicrobial treatment and/or urine cultures are needed. Yet the performance...
BACKGROUND
Clinicians and laboratories routinely use urinalysis (UA) parameters to determine whether antimicrobial treatment and/or urine cultures are needed. Yet the performance of individual UA parameters and common thresholds for action are not well defined and may vary across different patient populations.
METHODS
In this retrospective cohort study, we included all encounters with UAs ordered 24 hours prior to a urine culture between 2015 and 2020 at 3 North Carolina hospitals. We evaluated the performance of relevant UA parameters as potential outcome predictors, including sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). We also combined 18 different UA criteria and used receiver operating curves to identify the 5 best-performing models for predicting significant bacteriuria (≥100,000 colony-forming units of bacteria/mL).
RESULTS
In 221,933 encounters during the 6-year study period, no single UA parameter had both high sensitivity and high specificity in predicting bacteriuria. Absence of leukocyte esterase and pyuria had a high NPV for significant bacteriuria. Combined UA parameters did not perform better than pyuria alone with regard to NPV. The high NPV ≥0.90 of pyuria was maintained among most patient subgroups except females aged ≥65 years and patients with indwelling catheters.
CONCLUSION
When used as a part of a diagnostic workup, UA parameters should be leveraged for their NPV instead of sensitivity. Because many laboratories and hospitals use reflex urine culture algorithms, their workflow should include clinical decision support and or education to target symptomatic patients and focus on populations where absence of pyuria has high NPV.
Topics: Female; Humans; Pyuria; Bacteriuria; Urinary Tract Infections; Retrospective Studies; Urinalysis; Reflex; Urine
PubMed: 36625063
DOI: 10.1017/ice.2022.315 -
The Journal of Small Animal Practice Apr 2022To determine the effect of urine-specific gravity (USG) on using microscopic evaluation of bacteriuria to predict urine culture results in dogs and cats.
OBJECTIVE
To determine the effect of urine-specific gravity (USG) on using microscopic evaluation of bacteriuria to predict urine culture results in dogs and cats.
MATERIALS AND METHODS
We performed a retrospective medical record review of canine and feline patients that had a urinalysis and urine culture performed simultaneously. The sensitivity, specificity, positive predictive value and negative predictive value of microscopic bacteriuria for predicting urine culture results were calculated, stratified by USG. Multivariable regression was performed to test the effect of USG, pyuria, haematuria and species on the agreement between microscopic bacteriuria and culture results.
RESULTS
A total of 481 dogs and 291 cats with paired urinalysis and urine culture results were included in the study. Microscopic bacteriuria had moderate sensitivity (76% in dogs, 64% in cats) and high specificity (97% in dogs, 96% in cats) for predicting urine culture bacterial growth. Samples with rod bacteria were more likely to have bacterial growth than those with cocci (OR=Infinity, 95% CI 4.8 - Infinity). As compared to isosthenuric+hyposthenuric samples (USG ≤1.012), agreement was lower in moderately concentrated (OR=0.44, 95% CI 0.19 to 0.91) samples. Absence of bacteriuria, pyuria and haematuria had a high negative predictive value for no bacterial growth (96%).
CLINICAL SIGNIFICANCE
Microscopic bacteriuria has a high specificity in predicting urine culture results, regardless of USG. The finding that microscopic bacteriuria has better agreement with urine culture results in isosthenuric+hyposthenuric urine argues against reflex culture in these samples, especially if pyuria and haematuria are also absent. Urine microscopy can aid clinicians in determining the likelihood of urine culture growth.
Topics: Animals; Bacteriuria; Cat Diseases; Cats; Dog Diseases; Dogs; Female; Hematuria; Male; Microscopy; Pyuria; Retrospective Studies; Specific Gravity; Urinalysis; Urinary Tract Infections; Urine
PubMed: 34897695
DOI: 10.1111/jsap.13456