Spot the diagnosis and discuss further management



Dear All,


A 2-month-old boy developed febrile UTI, with a positive urine culture for E. coli. He was hospitalized and received IV antibiotics a year ago.


Pre-natal findings:

Ultrasound was suggestive of right HUN, with the right kidney being smaller in size compared to the left. The left kidney, bladder, and post-void residual (PVR) were normal.


Clinical details:

Serum creatinine: 0.34 mg/dL at 2 months of age.

VCUG was performed after infection control, and the patient was started on antibiotic prophylaxis.


I am attaching the VCUG images for your review.


Kindly provide your diagnosis and share your thoughts on further management.


Thank you.



Spot the diagnosis and discuss further management

Comments(18)

  • Abdulhakim alotay
    Abdulhakim alotay
    27 Nov 2024 08:23:07 PM

    Interesting case 

    Thanks Anil for sharing the case . 

    Am am suspecting 2 pathology here 
    Obstructeing refluxing ureter and poor functioning kidney . 

    Will order DMSA and continue abx if things getting worse and kidney has function I elect to go for diversion 

  • Yaqoub jafar
    Yaqoub jafar
    27 Nov 2024 08:49:54 PM

    Hi Anil  it’s really interesting case . 

    I have some question , did the child had ultrasound spine? 
    The VCUG look high grade VUR but the bladder is trabeculated mildly .  
    Would you consider cystoscopy to role out PUV in this child ? 
    I may consider it to be honest , and I will for sure do circumcision for the child . 
    For me it’s not obstructing refluxing megaureter as the concentration of the contrast is similar in the kidney and the bladder . 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    27 Nov 2024 09:21:30 PM

    Spine is normal in USG and X ray 

    Bladder reported normal 
    No significant PVR
    Parents have no complaints regarding urinary stream 
    I am trying to attach first photo of first post natal USG
    Regarding diagnosis and further management let others to share their thoughts 
    Thanks 

  • Dr. Aadil Farooq
    Dr. Aadil Farooq
    27 Nov 2024 11:26:11 PM

    Sir,

    Thank you for sharing intersting cases.
    We are dealing with a good number of such cases at our Pediatric Urology centre and doing good.
    These cases require confidence,faith and patience on the part of treating doctor and parents.
    Here it's a High pressure bladder with High grade VUR.
    I would ask parents to see and record the voiding pattern of child if normal or stressful.
    Posterior Urethra is elongated and dilated.
    I will do circumcision and Cystoscopy then catheter placement.
    Continue antibiotic prophylaxis and keep urine sterile.
    Support the child to grow along with the kidneys.
    Once there is no more obstruction distally, bladder will begin to behave normally,no more deterioration in compliance.
    Meticulous follow up is necessary.
    Diversion is done only in case of Pyonephrosis.
    Sincere Regards,
    Dr. Aadil Farooq.
    Consultant,
    Pediatric Urology.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    28 Nov 2024 08:11:17 AM

    This is most probably a refluxing an obstructing megaureter if you see the drainage image the bladder drains well, but not the ureter or the collecting system.

    I would go ahead and a cuteneostomy ( ureteric diversion) and undivert in a year with right reimplant of ureter.

    From Prof. Serdar Tekgul, Turkey 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Nov 2024 08:48:30 AM

    Patient kept on AB prophylaxis 


    I am attaching the DMSA scan of this patient done almost at 12 weeks of age

    Please discuss 

  • Yaqoub jafar
    Yaqoub jafar
    29 Nov 2024 11:43:36 AM

    Good morning Anil , 

    Thank you for the amazing work , 
    After seeing the DMSA scan , it look for me as it’s pop off effect , with this finding , I have to scope the child . To make sure it’s not of the PUV as some PUV type the don’t have all classical finding  .  My DDX is either PUV or obstructing refluxing megaureter . The refluxing obstructing megaureter  can be due to hypertrophied bladder detrosral muscular due to BOO as it was published by sick kid team . I would scope the child and if the child had no  PUV or one of its variant I will circumcise him  and can . 
    CIC is option . 
    If all the measure fails I would consider ureterostomy . 
    With kind regards , 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Nov 2024 11:54:40 AM

    Bladder not thick

    Bladder neck not elevated 
    No PVR on USG and VCUG
    Urinary stream is good as per parents 
    Most of the refluxed contrast stays in upper track even in post micturation film of VCUG
    Thanks 

  • Abdulhakim alotay
    Abdulhakim alotay
    29 Nov 2024 02:44:33 PM

    Thanks Anil for update, 

    I am still with my first comment as this is a case of obstructing refluxing megaureter . 
    With such DMSA and acceptable function ,and this boy is still 2 months age , I will continue abx and observe him if he develop break through infection or worsening hydro. I will proceed for cystoscope and diversion, otherwise , I will give chance for spontaneous resolution as this is the fate of most megaureter cases . 

    Regards ????

  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Nov 2024 04:24:45 PM

    Great responses 

    What type of diversion you will prefer in this patient?
    I concur with your comments and pathway 

    Thanks 

  • Abdulhakim alotay
    Abdulhakim alotay
    29 Nov 2024 04:33:11 PM

    Thank Anil , 


    I prefer as prof. Serdar recommended . Cutaneous ureterostomy ,, although many recent reports about JJ stenting promising with good result ( as internal drainage ) , but as long term and unilateral , cutaneous urterostomy more safe and efficient 

    Regards 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Nov 2024 04:42:24 PM

    End Ureterostomy or low loop ureterostomy?

    Please share your reasons for selecting the type of diversion.

    I agree with ureteric diversion 
    Thanks 

  • Abdulhakim alotay
    Abdulhakim alotay
    29 Nov 2024 04:51:32 PM

    Distal Loop ureterostomy 


  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Nov 2024 04:56:06 PM

    I did the same when patient was almost of 3 months age. 

    They wanted circumcission, we did that along with low cutaneous loop ureterostomy.
    My reason is, it is very easy to perform and it is effective in serving the purpose.
    But I know few will prefer low end ureterostomy in this case. 
    We will try to get few more expert comments on that 

    Thanks 

  • Abdulhakim alotay
    Abdulhakim alotay
    29 Nov 2024 05:01:57 PM

    Perfect and great work Anil 


  • Dr.Sneh shah
    Dr.Sneh shah
    29 Nov 2024 06:06:41 PM

    So as I understand this boy is 14 month of age right now and had febrile culture positive uti  a year ago when he was 2 month of age..all these investigation posted are when he was 2 month old. Is MCU is when he was 2 month or recent?

    So what's current history?any breakthrough Uti after starting prophylactic antibiotics?

  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Nov 2024 06:58:08 PM

    Dear All,

    Posting time line of this case:
    Present age: 14 months
    Prenatal diagnosis of right HUN during 3rd trimester
    Febrile UTI-2 months of age, hospitalization, iv antibiotics
    USG done during that episode, attaching the report as pictures are not available
    Was kept on AB prophylaxis
    VCUG was done, picture is already provided
    Had  one episode of breakthrough infection
    He presented to me at around 3 months age
    DMSA scan was advised by me, photo of DMSA already provided
    At around 3 month I did low cutaneous uretrostomy on right side as a diversion as my diagnosis was an obstructive, refluxing dilated ureter with recurrent PN ( / infected HN )
    Child had one episode of febrile UTI within 3 to 4 weeks of ureterostomy, upper limb of uretrostomy was found to be blocked by pus flakes. He was treated. Since then no issues, grown well. Present weight is 11 Kg

  • Serdar Tekgul
    Serdar Tekgul
    30 Nov 2024 01:03:18 AM

    Hi An?l


    Sorry being late to login but thank you for sharing my reply to you.
    I believe the wall of the bladder is so smooth and the emptying is also well, I think these are enough findings to exclude PUV 

    But the right system is not draining well and already lost some function

    Jj stents have not shown to be a reliable management as the infections keep continuing in about 70%
    Cutenoestomy is a great choice as it helps drainage keeps infection away and more importantly helps in improving ureter size for a much easier reimplant later

    I would do loop if there is reflux to the contra?eral ureter and the bladder is problematic ( like in valve bl or neurogenic bladder) refluxing stoma will help the drainage of the bladder
    For this case I eould end cutonestomy


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