Intern Seminar

Renal Abscess in ChildrenVS 邱元佑R4 周信旭

Speaker 陳如蘋

Brief Hx13y/o female, 165 cm/ 98 kgC.C.: fever and headache for 3 days

Impression: r/o meningitis, r/o gastritis

fever and headache for 3 days

Vomiting noted persistent

fever

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

Lab 92/12/07

CBC: WBC 24.3K / Band 23% / Seg65%Chem: CRP 82.8U/A: WBC 6-8 / RBC 10-12

Clinical Course

Fever(+),

Watery diarrhea ~3/d

Stool OB(-) Rotavirus Ag rapid dx(-) Stool culture(-) Renal echo

12/8

Fever(+), watery diarrhea(+) ~1 time/dPE: mild tenderrness over LUQ

12/ 10

U/A:WBC 1-2 RB

C 3-4 U/C: E.coli (91,00

0CFU/ml)

Lab: WBC 7.8K Band 27% Seg 40% CRP 91.2

12/11

Abdominal CT

Pre- Contrast Post- Contrast

Abdominal CT

Pre- Contrast Post- Contrast

Abdominal CT

Pre- Contrast Post- Contrast

Fever CurveBT

333435363738394041

12/0

7.4a

m

12/7

12/8

12/9

12/1

0

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1

12/1

1

12/1

2

12/1

3

12/1

4

12/1

5

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5

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6

12/1

7

BT

Keflin + GM Unasyn + Amikin

Discussion

Renal Abscess in Children

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

Introduction

Three pathophysiologic mechanisms:1.Hematogenous spread2.Ascending infection3.Contamination by proximity to an infe

cted area

Intrarenal abscess

Renal cortical abscess: a primary focus of infection

elsewhere in the body S. aureus

Renal corticomedullary abscess: ascending infection E. coli

1996-2000: 8/ 473 UTI children

Acta Pediatr Tw 2003; 44: 197-201

1996-2000: 8/ 473 UTI childrenChild Age/ Max. T S/S CRP Leukocy

teNo. Sex (0C) (103/ml)

1 6mo/M 40.5 Fever 99.3 19.8

2 17mo/F 39 Abdominal pain, fever 87.4 10.5

3 156mo/F 39.3 Poor activity, poor appetite, fever 267 34.9

4 23mo/F 40 Fever, mixed with URI 521.7 49.7

5 43mo/F 41 Abdominal pain, vomiting, fever 229 11.4

6 60mo/F 39.9 Abdominal pain, vomiting, fever 349.9 13.4

7 26mo/F 39 Poor appetite, vomiting, fever 22.2 21

8 36mo/F 40 Abdominal pain, poor appetite, 184.1 61 fever*U/C: all E. coli except No. 2 and 7 were sterile

Febrile days before admission seems parallel

to febrile days after antibiotics treatment

Acta Pediatr Tw 2003; 44: 197-201

No.

U/S CT Renal SPECT - initial

Renal SPECT - followed

VU reflux

1 Bil. APN R’t ABN with small abscesses

Bil. APN Normal No

2 Bil. APN, R’t upper abscess

R’t multiple abscesses

Bil. APN Bil renal scar

No

3 Bil. APN Bil. ABN with abscesses

Bil. APN R’t renal scar

No

4 Bil. APN R’t multiple abscesses

Bil. APN Bil renal scar

No

5 L’t renal abscess

L’t multiple abscesses

Mixed Ch. and Ac. L’t PN renal scar

L’t grade I

6 L’t APN L’t multiple abscesses

Bil. APN NA NA

7 Bil. APN, r/o ABN or abscess

R’t multiple abscesses

NA Normal R’t grade II

8 L’t APN, r/o ABN or abscess

L’t multiple abscesses

L’t APN L’t renal scar

L’t grade III

1990-2000: 6 p’ts / University of Texas Medical Branch

Pediatr Surg Int (2003) 19: 35–39

Signs and symptoms

Pediatr Surg Int (2003) 19: 35–39

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)

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

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.

US findings: 5y/o F FUO

12/10 12/12

DMSA renal SPECTA noninvasive imaging studyHigh sensitivity and specificity to detect renal inflammation (sensitivity of detecting APN ~96%) Less useful to detect anatomic change

TreatmentHigh 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. 3rd cephalosporins, broader-spectrum penicillins or intravenous TMP-SMX is equivalent to empiric combination therapy.

Treatment

Large(> 5cm) and medium(3-5cm) renal abscesses: open Sx

Reported kidney loss: 16-25%

Table 3. Treatment algorithm

Pediatr Surg Int (2003) 19: 35–39

Thanks for Your Attention!

Pediatrics 2000; 105:E59

Pediatrics 2000; 105:E59

Pediatrics 2000; 105:E59