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Intern Seminar

Intern Seminar. Renal Abscess in Children VS 邱元佑 R4 周信旭 Speaker 陳如蘋. Brief Hx. 13y/o female, 165 cm/ 98 kg C.C.: fever and headache for 3 days Impression: r/o meningitis, r/o gastritis. fever and headache for 3 days. Vomiting noted. persistent fever.

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Intern Seminar

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  1. Intern Seminar Renal Abscess in Children VS 邱元佑 R4 周信旭 Speaker 陳如蘋

  2. Brief Hx • 13y/o female, 165 cm/ 98 kg • C.C.: fever and headache for 3 days • Impression: r/o meningitis, r/o gastritis fever and headache for 3 days Vomiting noted persistent fever

  3. Physical Examination • Head: Kernig sign (-), Bruzinski sign (-) conj: not anemic; sclera:not icteric throat: not injected; eardrum: intact • Abd: soft and obese, mild tenderness(+) over LUQ, rebounding pain(-), muscle guarding(-), flank pain(-), BS: hyperactive

  4. Lab 92/12/07 • CBC: WBC 24.3K / Band 23% / Seg65% • Chem: CRP 82.8 • U/A: WBC 6-8 / RBC 10-12

  5. Clinical Course Fever(+), watery diarrhea(+) ~1 time/d PE: mild tenderrness over LUQ Fever(+), Watery diarrhea ~3/d 12/8 12/ 10 12/11 Stool OB(-) Rotavirus Ag rapid dx(-) Stool culture(-) Renal echo Lab: WBC 7.8K Band 27% Seg 40% CRP 91.2 U/A: WBC 1-2 RBC 3-4 U/C: E.coli(91,000CFU/ml)

  6. Abdominal CT Pre- Contrast Post- Contrast

  7. Abdominal CT Pre- Contrast Post- Contrast

  8. Abdominal CT Pre- Contrast Post- Contrast

  9. Fever Curve Keflin + GM Unasyn + Amikin

  10. Discussion Renal Abscess in Children

  11. Introduction • Renal abscess is rare in children and diagnosis may be difficult. • Incidence rate: 1-10 per 10,000 hospital admissions. • Steele et al 1990: renal abscess with peak incidence between 7-9 years

  12. Introduction • Three pathophysiologic mechanisms: • Hematogenous spread • Ascending infection • Contamination by proximity to an infected area

  13. Intrarenal abscess • Renal cortical abscess: a primary focus of infection elsewhere in the body S. aureus • Renal corticomedullary abscess: ascending infection E. coli

  14. 1996-2000: 8/ 473 UTI children Acta Pediatr Tw 2003; 44: 197-201

  15. 1996-2000: 8/ 473 UTI children Child Age/ Max. T S/S CRP Leukocyte No. Sex (0C) (103/ml) • 6mo/M 40.5 Fever 99.3 19.8 • 17mo/F 39 Abdominal pain, fever 87.4 10.5 • 156mo/F 39.3 Poor activity, poor appetite, fever 267 34.9 • 23mo/F 40 Fever, mixed with URI 521.7 49.7 • 43mo/F 41 Abdominal pain, vomiting, fever 229 11.4 • 60mo/F 39.9 Abdominal pain, vomiting, fever 349.9 13.4 • 26mo/F 39 Poor appetite, vomiting, fever 22.2 21 • 36mo/F 40 Abdominal pain, poor appetite, 184.1 61 fever *U/C: all E. coli except No. 2 and 7 were sterile

  16. Febrile days before admission seems parallel to febrile days after antibiotics treatment

  17. Acta Pediatr Tw 2003; 44: 197-201

  18. 1990-2000:6 p’ts / University of Texas Medical Branch Pediatr Surg Int (2003) 19: 35–39

  19. Signs and symptoms Pediatr Surg Int (2003) 19: 35–39

  20. A renal abscess should be considered • In any child present with fever, abd pain, flank pain, costovertebral angle tenderness, + a palpable mass, leukocytosis, elevated ESR • In p’ts with sonographic evidence of focal bacterial pyelonephritis (25% risk of progression)

  21. Risk Factors • Anatomic or functional uropathy, esp. VUR Pediatrics 2002; 109:165-6 • Recent urologic or abdominal Sx Pediatrics 1994; 93:261-4 • Recent concomitant infections Pediatr Infect Dis J 8:167-70

  22. Image study for renal abscess - US and CT • US and CT greatly facilitate the diagnosis and permit the percutaneous drainage of renal abscess in pediatric age group. • Although ultrasound is the best modality for imaging a renal abscess, computed tomography provides better tissue contrast, especially in obese patients.

  23. US findings: 5y/o F FUO 12/10 12/12

  24. DMSA renal SPECT • A noninvasive imaging study • High sensitivity and specificity to detect renal inflammation (sensitivity of detecting APN ~96%) • Less useful to detect anatomic change

  25. Treatment • High cure rate! • Small abscesses (< 3cm) in immunocompetent p’ts:IV A/B and/or percutaneous drainage 1. Initial : aminoglycoside and either ampicillin or cephalosporin. 2. 3rdcephalosporins, broader-spectrum penicillins or intravenous TMP-SMX is equivalent to empiric combination therapy.

  26. Treatment • Large(> 5cm) and medium(3-5cm) renal abscesses:open Sx • Reported kidney loss: 16-25%

  27. Table 3. Treatment algorithm Pediatr Surg Int (2003) 19: 35–39

  28. Thanks for Your Attention!

  29. Pediatrics 2000; 105:E59

  30. Pediatrics 2000; 105:E59

  31. Pediatrics 2000; 105:E59

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