ABDOMINAL PAIN AND DYSURIA
History
Leah is a 5-year-old girl who has been passing urine frequently for the last 2 days and complaining of pain when doing so. Her parents have brought her to A&E today because they measured a temperature of 39C using a forehead thermometer and she had an episode of violent shivering. She has also complained of pain in her back and has vomited three times today. Leah had oesophageal atresia with a tracheo-oesophageal fistula diagnosed at birth. Her parents remember that some tests were done at birth but no other abnormalities were found. She has no history of urinary infections. They have moved home four times since she was born and have not had any follow-up for years. She is generally healthy and has recently started school, which she enjoys.
Examination
She is flushed and miserable. Her temperature is 39.1C, heart rate 130 beats/min, respiratory rate 25/min, and her oxygen saturation is 99 per cent in air. Capillary refill is 2 s, heart sounds are normal and her chest is clear. She has a mild kyphoscoliosis. Her abdomen feels soft and is not distended, but there is significant discomfort when palpating the right loin. Her external genitalia appear normal. Her weight is 17 kg (25th centile).
INVESTIGATIONS
Normal
Urine dipstick
Leucocytes +++ Negative
Nitrites Positive Negative
Blood Trace Negative
Glucose Negative Negative
Protein Negative Negative
Questions
• What is the diagnosis?
• How would you manage this child?
• What underlying diagnosis might be considered?
Medicine
This child’s clinical features and urine dipstick results are consistent with a urinary tract infection (UTI). The combination of leucocytes and nitrites on urine dipstick is highly predictive of a UTI. Urine dipstick should be a routine part of the assessment of a febrile child. It is important to recognize that the history and physical findings suggest that this is more than just cystitis. She has probably had a rigor, which may indicate bacterial products entering the bloodstream, she is systemically unwell and she has loin tenderness. These findings point to the diagnosis of pyelonephritis.
Symptoms of a urinary tract infection
• Infant – fever, vomiting, lethargy, irritability, poor feeding
• Older child – frequency, dysuria, abdominal pain or loin pain, fever
It is useful to collect two midstream urine specimens before starting intravenous antibiotic therapy, so that the diagnosis of UTI can be confirmed. It is important to avoid contamination by skin flora, by cleaning the external genitalia first and then catching urine cleanly from the middle of the stream (i.e. do not collect the first drops) without the container touching the skin. This should then be sent for microscopy and bacterial culture. Her blood pressure should be measured and, during cannulation, blood should be sent for a full blood count, C-reactive protein, urea, electrolytes, creatinine and blood culture. Further questioning should determine if there have been previous urine infections, recurrent fevers of uncertain origin, a previously diagnosed renal abnormality, a family history of vesicoureteric reflux or constipation. In infants under 6 months and in older children with severe, atypical or recurrent urinary infections, imaging is required to determine if there is an underlying renal abnormality. Leah will therefore require an ultrasound of her urinary tract in the next few days. Prophylactic antibiotics are no longer used routinely after a first urinary tract infection but may be required in children with recurrent urinary infections. Leah may have an underlying structural renal tract abnormality predisposing to infection. The VACTERL association is the sporadic, non-random, concurrence of at least three of: vertebral, anal, cardiac, tracheo-oesophageal, renal and limb abnormalities. She should also have spinal X-rays to determine the cause of her kyphoscoliosis, e.g. a hemivertebra (see Case 60, p. 183). It would be useful to obtain her previous medical records to find out more about her previous history and investigations.
KEY POINTS • Urinalysis should be performed in any unwell, febrile child. • In infants under 6 months and in older children with severe, atypical or recurrent urinary infections, imaging is required to determine if there is an underlying renal abnormality.
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