COVID TIME -Bilateral high grade reflux with recurrent febrile episodes

• 14 May 2020 08:16:12 AM
• |Pediatic Urology

3 and half years male child presented with history of recurrent febrile episodes in last one year.  None of the time,  urine evaluated for underlying UTI. 

Comments(13)

• 

  Sudip Das Gupta

  14 May 2020 08:52:14 AM

  Ultrasonogram can be done to assess renal scarring and renal function during this time.

• 

  Sudip Das Gupta

  14 May 2020 09:17:41 AM

  Through usg can't we get information regardibg scarrring and cmd ratio for renal function?

• 

  Gyanendra Sharma

  14 May 2020 10:15:38 PM

  When DMSA was not available the only functional study available was IVU

  In this patient my line of management --in this Covid time --would be

  1. Culture specific antibiotics for 10--14  days
  2. Confirm that urine is sterile 
  3. Circumcision if there is phimosis
  4. Start him on Chemoprophylaxis
  5. Look  carefully for symptoms suggestive bladder dysfunction  & rule out / manage constipation
  6. as my present plan is not to intervene surgically --DMSA scan would be advised when it is available

  
  

• 

  Dr. Anil Takvani

  14 May 2020 10:35:58 PM

  Thanks.

  Patient is on AB prophylaxis since 3 weeks.

  No voiding or bowel issues.

  Child is toilet trained, no voiding issues

  Would you consider base line functional study as we don't know how far renal damage has taken placed because of previous febrile episodes?

  DMSA will not be possible for long, what you will do if breakthrough infections?

  Role of circumcision is matter of debate in child above one year agr or toilet trained child...

• 

  Rahul Kapoor

  15 May 2020 07:08:34 AM

  In this COVID emergency, start culture specific AB. 

  Will plan a baseline USG and look for both kidney size and contour. Renal scans are not done anywhere. If child remain stable, just wait and follow. Get a DMSA later date. 

  As Dr Gyanendea suggested, IVP can give some information. 

  For more anatomical details, CT and MRI can give anatomical details with suggestions of damage. Usually CT is not indicated due to radiation exposue. 
  

  But i dont know is their a role of CECT or MRI. 

  
  

  
  

• 

  Rahul Kapoor

  15 May 2020 07:33:12 AM

  Diffusion-weighted magnetic resonance imaging is more sensitive than dimercaptosuccinic acid scintigraphy in detecting parenchymal lesions in children with acute pyelonephritis: A prospective study

  Alice BosakovaaCorrespondence information about the author Alice BosakovaEmail the author Alice Bosakova

  , 

  Dana Salounovab

  , 

  Jaroslav Havelkac

  , 

  Otakar Kraftd

  , 

  Pavel Sirucekd

  , 

  Radim Kocvarae

  , 

  Michal Hladik

  DOI: https://doi.org/10.1016/j.jpurol.2018.02.014

  
  

  
  

  
  

  
  

   

                                                              

                     Introduction

  Static renal scintigraphy is the gold standard for detection of inflammatory changes in the renal parenchyma in acute pyelonephritis. Our aim was to determine whether diffusion-weighted magnetic resonance imaging (DW-MRI) was comparable with static renal scintigraphy (DMSA-SRS) to demonstrate acute renal parenchymal lesions.

  Objective

  To compare 99mTc-dimercaptosuccinic acid static renal scintigraphy (DMSA-SRS) with diffusion-weighted magnetic resonance imaging (DW-MRI) for detecting acute inflammatory changes in the renal parenchyma in children with febrile urinary tract infection.

  Methods

  Thirty-one children (30 girls) aged 3–18 years with a first episode of febrile UTI without a previously detected congenital malformation of the urinary tract, were prospectively included. DMSA-SRS and DW-MRI were performed within 5 days of diagnosis to detect renal inflammatory lesions. The DW-MRI examination was performed without contrast agent and without general anesthesia. Late examinations were performed after 6 months using both methods to detect late lesions.

  Results

  DW-MRI confirmed acute inflammatory changes of the renal parenchyma in all 31 patients (100%), mostly unilateral. DMSA-SRS detected inflammatory lesions in 22 children (71%; p = 0.002). The lesions were multiple in 26/31 children (84%) on DW-MRI and in 9/22 (40%) on DMSA-SRS. At the control examination, scarring of the renal parenchyma was found equally by DW-MRI and DMSA-SRS in five patients (16%), three of whom were the same patients. The overall concordance of positive and negative late findings occurred in 87% of patients. There was correspondence in the anatomical location of acute and late lesions.

  Discussion

  The clinical significance of acute and late parenchymal findings on DWI-MR is yet to be determined. A limitation of our study is the age of the patients (older than 3 years) who are less sensitive to scar development; therefore, a smaller number of patients with scars could be analyzed during control examination. Further studies using the DW-MRI should confirm its reliability to detect acute and late lesions in younger children and infants and determine the clinical consequences.

  Conclusion

  DW-MRI has higher sensitivity for detecting acute renal inflammatory lesions and multifocal lesions than DMSA-SRS. The incidence of scars was low and corresponded with the anatomical location of acute and late lesions

• 

  Dr. Aadil Farooq

  15 May 2020 11:35:12 AM

  Sir, With all the limitations of pandemic, I would like to have proper history including pain lumbar/ suprapubic, fever, chills, anorexia, dysuria, frequency. I shall measure BP to rule out hypertension. Often I ask for voiding video with lower abdomen so I can see the stream and abdominal straining which is often missed. Next I will assess education level and social status to teach the parents about toilet training and Prepucial care & perineal hygiene. Also dietary advice to avoid constipation. Sir, there is significant intestinal gas shadow on VCUG. Next Urine examination to see for proteinuria, dysmorphic RBCs, abd granular casts s/o parenchymal involvement, along with leucocyte esrerase and nitrite. Urine culture. USG KUB with PT, CMD, Renal Size and scars grossly and PVR. Treatment; Antibiotics oral based on Culture sensitivity. I.V. Antibiotics for recurrent febrile episodes with IV hydration. Toilet training and Prepucial & perineal hygiene. Treat constipation. Liquids and proper diet. Later on DMSA, Urine Routine and Culture, Uroflowmetry. Please guide, Sincere Regards.

• 

  Dr. Isteaq Shameem

  15 May 2020 08:06:57 PM

  Dr Isteaq Shameem

  Not only during pandemic treatment options may change post pandemic in few cases. Since DMSA is not possible now which could have given the relative renal function and scarring,antibiotics prophylaxis should continue. Even without lockdown DMSA would have been preferred at least 3 months after acute febrile episode as there are intraparenchymal inflammatory reaction that accompany UTI. 

  It is true that the role of circumcision in a toilet trained child is not beyond debate but still may be helpful.Child BP measurement can be important to have an understanding of renal scarring

  We may have to rethink if there is persistent fUTI despite antibiotic prophylaxis and meantime if we can have DMSA

  At present antibiotic prophylaxis and proper bladder emptying with double voiding, avoiding constipation and parents compliance are all needed

  Thank you all

  
  

• 

  Dr. Anil Takvani

  16 May 2020 09:25:03 AM

  Thank you all for very useful inputs...

  @ Dr Isteaq Shameem---Sir, this patient is giving history of previous three episodes of febrile events amounting to higher AB. So in my opinion there is no point in waiting for 3 months post recent febrile UTI in this patient. 
  

  Still we can wait as it is not an emergency.

  There are questions from parents regarding renal damages, how to answer those?

  If there are further breakthrough infections what will you prefer for functional study: IVU or MRI as both are available?

  Anyone has doubt of secondary PUJO on left side?

  Please post your expert comments...Thanks

• 

  Ramesh Babu

  19 May 2020 09:27:09 PM

  Recurrent febrile illnesses common in children. Unless we have a proven urine culture cant attribute it to UTI. Having said that some of them may be fUTI and DMSA is needed to prove scarring. 

  
  

  This child needs to go on continuous antibiotic prophylaxis (CAP) and followup to see whether there are any breakthrough UTIs. BBD needs to be probed and addressed. CAP compliance need to be ensured. Then decide later

• 

  SHIVAM PRIYADARSHI

  20 May 2020 11:15:02 PM

  On MCU if the renal pelvis is getting filled up with the dye so easily , it rules out the possibility of secondary PUJ on the left side.

  The patient should be put on chemoprophylaxis. If he has breakthrough infection he becomes a candidate for reflux surgery whether DMSA scan is done or not.

• 

  Dr. Anil Takvani

  21 May 2020 06:16:24 AM

  @ Shivam,

  Is it advisable to operate without documenting renal function? ( in a set up of breakthrough infections )

  Why not limited plate IVU as mentioned by Dr. Gyanendra?

  Thanks

• 

  SHIVAM PRIYADARSHI

  21 May 2020 05:04:31 PM

  @Dr. Anil. Yes IVU definitely can be done to know the function. We were talking about Scan for confirming scars.