Case study: renal

Question 1

A 6 month old girl presents with 3d of fever (>39o), vomiting, poor feeding, being unsettled and having strong smelling urine.
Examination showed RR 40, HR 150, no focal findings in the chest, abdomen, ears or throat

1. Diagnosis and differential?
2. Investigations
3. Management?

Answer 1

1. Urinary tract infection
   ?LRTI/ Pneumonia
   Consider other abdominal foci
2. Urine dipstix, microscopy and culture
   Consider FBC/ CRP, CXR, Throat swab if negative
3. Admit, IV 3rd gen.
   Cephalosporin or co-amoxiclav
   Keep well hydrated

Follow-up Renal USS/ DMSA +/- MCUG

Question 2

ccx of UTI?

Answer 2

septic shock

more common in infants

Question 3

1st line investigation of UTI?

Answer 3

Clean catch/ mid stream recommended (practical?)
Pads and bags used (generates false positives)
SPBA/ Catheter (invasive/ specialist decision)
Treatment is priority if acutely unwell

Question 4

what to look for in investigation of UTI?

Answer 4

Dipstix: nitrites/ Leucocyte esterase activity
Pyuria (some labs give provisional report)
Bacturia (takes 48h)

Question 5

treatment of lower tract UTI?

Answer 5

Oral trimethoprim/ co-amoxiclav

Question 6

treatment for Plyonephritis (well):

Answer 6

Oral antibiotics (not infants)

Question 7

treatment for Pylonephritis (unwell):

Answer 7

IV 3rd gen. Ceph/ Co-amox

Question 8

ccx of UTI?

Answer 8

reflux (VUR)

renal scarring

Question 9

follow up after UTI?

Answer 9

Renal USS (hydronephrosis/ kidney size) (All <3y)
DMSA (isotope scan for scarring)
MCUG (younger) MAG3 (older) for reflux if scarred

Question 10

A 3y old boy presents with 5 days of vomiting and bloody diarrhoea. He is tolerating oral fluids and recently visited a petting zoo
Examination showed no fever, HR 100, RR 25, no skin changes and mild general abdo discomfort

1. Diagnosis, causes
2. potential complications?
3. Investigation
4. management?

Answer 10

1. Gastroenteritis (Ecoli 0157, Campylobacter, Salmonella, shigella, yersinia),
   ?IBD if prolonged

ecoli- bloody diarrea

2. Potential Haemolytic Uraemic Syndrome
3. Stool cultures (bacterial and viral)
   Urine dipstix and blood pressure
   Check blood count and film, U+Es, LDH
4. Good hydration (low threshold for IV if HUS risk)
   Monitor urine output/ fluid balance
   Monitor bloods (HUS can present 10-14d later)
   May require dialysis +/- blood/ platelet Tx
   Antibiotics not indicated
   Parental information
   Notify public health

Question 11

how to asses hydration?

Answer 11

Alertness/ conscious level?
Fontanel (if present)- sunken or level?
Sunken eyes?
Dry or moist tongue/ lips?
Heart rate? CRT? Resp rate?
Peripheral warmth or coolness? (hands / feet)
Skin turgor?
Weight loss/ urine output- ?difficult to quantify

Question 12

When does HUS develop?

Answer 12

10-15% of Ecoli-0157 cases

Question 13

triad of HUS?

Answer 13

Microangiopathic haemolytic anaemia (fragments)
Thrombocytopenia (platelet consumption/ bruising)
Acute renal failure (potential multi-organ involvement)

Question 14

most common cause of acute renal failure?

Answer 14

Most common cause of acute renal failure

Most commonly post diarrhoea
Verotoxin producing E coli (O157 commonest) (~15%)
Shigella (Shiga toxin)

Question 15

A 9y old boy is brought is because parents are concerned that he still wets the bed most nights.
He has no fever and abdominal/ spinal/ neuro examination is normal.

1. What is the likely diagnosis?
2. What other information do you need to gather?
3. Investigations?
4. Management options?

Answer 15

1. Primary nocturnal enuresis (~15% 5y, 5% 10y, B>G)
   (Syn. Intermittent nocturnal incontinence)

2.Day time dryness? Wetting? Urgency? Frequency?
Fluid consumption: volume and timing
Constipation/ stool pattern

3.
Urine dipstix +/- Culture, ?USS for pre/ post volumes

4.
Increase daytime fluids (water not juice)
Decrease night fluids
Pads and alarms (bladder training)
Consider desmopressin +/- oxybutynin

Question 16

differnce between upper urinary tract infection

Answer 16

upper have systemic symptoms:
fever
vomiting
loin pain if older