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Pediatric Pyelonephritis

Author: Robert W Tolan Jr, MD; Chief Editor: Russell W Steele, MD more...

http://emedicine.medscape.com/article/968028-differential Background
indings on nuclear renal scans suggest that the vast majority of infants and young children with febrile urinary tract infections (UTIs) have acute cases of pediatric pyelonephritis. Early recognition and prompt treatment of UTIs, which are relatively common infections in children, is important to prevent late sequelae, such as renal scarring, hypertension, and renal failure. [1] When assessing the pediatric patient with UTI, one may encounter few specific symptoms. Older children are most likely to have symptoms attributable to the urinary tract. (See Treatment and Medication.) In the pediatric patient it may be difficult, and sometimes impossible, to differentiate pyelonephritis, an upper-tract infection, from cystitis, a lower-tract infection that is characterized by voiding-related symptoms with or without fever and often without other systemic signs. Febrile UTI should be assumed to be pyelonephritis and treated accordingly. (See History, Physical Examination, and Workup.)

Dehydration is the most common acute complication of pyelonephritis. Intravenous (IV) fluid replacement is necessary in severe cases. Acute pyelonephritis may lead to renal abscess formation. Long-term complications include renal parenchymal scarring, [2] hypertension, decreased renal function, and, in severe cases, renal failure. (See Prognosis.)

Patient education
For patient education information, see Urinary Tract Infections.

UTIs are generally ascending in origin and caused by perineal contaminants, usually bowel flora. However, in neonates, infection is assumed to be hematogenous in origin rather than ascending. This feature may explain the nonspecific symptoms associated with UTI in these patients. After the neonatal period, bacteremia is generally not the source of infection; rather, UTI or pyelonephritis is the cause of the bacteremia. Bacterial pathogens are the most common cause of pyelonephritis. Bacterial sources of pyelonephritis include the following: Escherichia coli - This is by far the most common organism, causing more than 90% of all cases of acute pyelonephritis Klebsiella oxytoca and species Proteus species Enterococcus faecalis and species Gram-positive organisms, including staphylococcal species and group BStreptococcus- These are rare causes of acute pyelonephritis

Risk factors
High-grade vesicoureteral reflux (VUR) may increase the risk for pyelonephritis, and VUR has been reported in as many as 33% of children with acute pyelonephritis. Congenital or acquired anomalies, including dysplasia, hypoplasia, and obstruction, increase the risk for UTI, VUR, and pyelonephritis. Even in the absence of urinary tract abnormalities, cystitis may result in VUR or worsen preexisting VUR and lead to pyelonephritis. VUR increases the risk for and size of renal cortical lesions, although clinically significant lesions can develop in the absence of VUR. Delayed or incomplete voiding, as seen with neurogenic bladder, obstruction, or dysfunctional voiding increases the risk for urinary stasis and overgrowth of colonizing bacteria. Constipation may impair bladder emptying, leading to stasis and ascending infection.

Catheterization may increase the risk of introducing periurethral bacteria into the bladder. Clean intermittent catheterization leads to colonization of the bladder that might lead to pyelonephritis if stasis allows any infection to ascend. Boys who are uncircumcised have a risk of UTI that is 2.2% higher than that of circumcised boys. The risk of acute pyelonephritis is not established. Sexual activity may cause urethral inflammation, lead to bladder colonization, and increase the risk for acute pyelonephritis. Familial inheritance of susceptibility to pyelonephritis may be related to chemokine receptor inheritance. Host genetic factors that promote inflammation contribute to renal scarring. Interleukin (IL)-8 and CXCR1 polymorphisms, ACE insertion/deletion (ACE I/D) gene polymorphism, and tumor necrosis factor-[alpha] polymorphism have been identified as potential mediators to tissue fibrosis and subsequent renal scarring following acute pyelonephritis.[3]

Occurrence in the United States
The prevalence of pyelonephritis varies by age and sex. About 60-65% of children with febrile UTIs have acute pyelonephritis, as defined by presence of abnormalities of the renal cortex on dimercaptosuccinic acid (DMSA) scan.[4]In general, 2.7-4.1% of children younger than 2 years who have fever also have UTI, even if another source is identified. UTI is present in 17% of white girls younger than 2 years with fever (temperature >39C).

Race-, sex-, and age-related demographics

The prevalence of urinary infection is 5-fold greater in white children than in black children and 2-fold greater than in children of other races. The prevalence of UTI in uncircumcised males is 8 times greater than it is in circumcised males in the first year of life. In addition, the incidence of UTI is higher in uncircumcised male infants than in female infants. After age 12 months, UTIs are more frequent in girls than in boys. In neonates, infection is generally hematogenous in origin. Girls younger than 11 years have a 3-5% risk of infection. For boys younger than 11 years, the risk is 1%. Febrile infants are more likely (6-8%) to have UTI as a source of fever than they are to be bacteremic (< 1%). [5] Children aged 1-5 years have a 3-fold increased risk of acute pyelonephritis on DMSA scanning compared with infants, whereas children older than 5 years have a 4.5-fold greater risk of acute pyelonephritis when evaluated for febrile UTI.

Most cases of pyelonephritis respond readily to antibiotic treatment without further sequelae. Permanent renal scars develop in 18-24% of children after acute pyelonephritis. Treatment within 5-7 days from the onset significantly reduces the formation of renal scars. For patients with severe cases or chronic infections, appropriate treatment, imaging, and follow-up help to prevent long-term sequelae. VUR often resolves without permanent damage. Recurrent pyelonephritis in the setting of VUR may be an indication for ureteral reimplantation.

Morbidity and mortality

Acute mortality is uncommon and is related to sepsis. Generalized bacteremia or sepsis may develop from pyelonephritis. In patients younger than 2 years with acute pyelonephritis, 810% have bacteremia. Acute renal parenchymal injury occurs in 20-90% of children with acute pyelonephritis. About 40% of these children have long-term renal scarring, which may lead to hypertension and renal insufficiency. Risk factors for renal scarring include young age, treatment delay,

infection by P-fimbriated E coliand VUR. Treatment of pyelonephritis within the first 5-7 days after onset is necessary to prevent renal damage. Impaired renal tubular function and secondary pseudohypoaldosteronism may develop in infants with pyelonephritis. Infants may develop hyperkalemia and hyponatremia.

Signs and symptoms of urinary tract infection (UTI) and pyelonephritis vary with the age of the patient. Neonates often present with nonspecific symptoms of jaundice, hypothermia or fever, poor feeding, vomiting, and failure to thrive. Neonates, especially male newborns, may develop hyponatremia and hyperkalemia as a result of secondary pseudohypoaldosteronism. Infants and young children aged 2 months to 2 years often present with nonspecific symptoms of fever lasting longer than 48 hours, as well as with poor feeding, vomiting, and diarrhea. Their urine may be malodorous; hematuria may be noted. Preschoolers and school-age children present with fever for greater than 48 hours. They may complain of abdominal pain or flank pain. Vomiting, diarrhea, and anorexia may be present. Their urine is typically malodorous, and hematuria may be noted. Voiding-related symptoms including enuresis, dysuria, urgency, and frequency, may occur but need not be present. Adolescents are most likely to present with the classic adult symptoms of fever, often with chills, rigors, and flank pain. They may have abdominal and suprapubic pain, along with voiding-related symptoms of frequency, dysuria, and hesitancy. Their urine is most often malodorous, and hematuria is variably present.

Physical Examination
Because many symptoms of pyelonephritis are nonspecific, complete physical examination is necessary to exclude other causes of the patient's symptoms. Specific findings are as follows.

General appearance
Most infants and children are uncomfortable and appear ill. Older children and adolescents may be mildly to moderately ill.

Vital signs
Fever may be present, with body temperature of more than 38C, and often more than 39C. Tachycardia may be present, secondary to fever and pain. Blood pressure is usually normal. Hypertension should raise concern for clinically significant obstruction or renal parenchymal disease. Hypotension may occur if sepsis and shock are present.

Abdominal findings
Abdominal pain may be present. A mass may indicate obstruction, hydronephrosis, or another anatomic abnormality. Suprapubic pain may be present. A palpable bladder indicates obstruction or functional difficulty in starting or completing voiding. Adolescent girls may have right upper quadrant pain similar to that observed in patients with cholecystitis.

Back findings
Tenderness in the costovertebral angle (CVA), back, or flank is likely to be present in older children and adolescents. Sacral dimple or birthmarks overlying the spine may be associated with an underlying anomaly of the spinal cord. Vertebral abnormalities may be evident.

Genitourinary findings
Assess for irritation, pinworms, vaginitis, trauma, or signs of sexual abuse. A bulging hymen suggests an imperforate hymen and urethral obstruction.

Neurologic findings
Weak lower extremities or diminished reflexes may be signs of spinal-cord dysfunction, and they may be associated with a neurogenic bladder.

Diagnostic Considerations
UTI and pyelonephritis must be considered in young pediatric patients with fever and/or nonspecific symptoms so that this fairly common diagnosis is not overlooked.Identification and treatment of acute pyelonephritis in the first 5-7 days significantly decreases the risk of renal scarring. Conditions to be considered in the differential diagnosis of pyelonephritis include the following: Concurrent pregnancy Anatomic abnormalities of the urinary tract Vesicoureteral reflux Ureteropelvic junction obstruction Posterior urethral valves Ureterocele Vaginitis Fever of unknown origin Pelvic inflammatory disease Xanthogranulomatous pyelonephritis

2. http://icmr.nic.in/ijmr/2005/july/0701.pdf