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Case Report

Urinary Tract InfectionPEDIATRIC DEPARTMENTHAJI ADAM MALIK GENERAL HOSPITALFACULTY OF MEDICINE SUMATERA UTARA UNIVERSITYMEDAN2015Presented by: Widya Manja Putri(110100064)Tgk. Nurhasannah(110100272)

Supervisor:dr. H. Emil Azlin, SpA(K)

is defined by the presence of organisms in the urinary tract, which is usually sterile.

> 6 years

1 - 5 yearsBoys (0.1-0.2% ): girls (0.9-1.4%)< 1 yearBoys (2.7%): girls (0.7%)IncidencesAscending infection of the urinary tract is a complex process that has been associated with bacterial adhesion, virulence, and host anatomic, humoral, and genetic factors.

>80% Escherichia coliGram negative: Kleibsiella, Proteus, Enterobacter, and occasionally Pseudomonas.Gram-positive: group B Streptococcus, Enterococcus, and Staphlococcus saprophyticus.

More specific signs and symptoms as the child grows older. A third of these patients have some symptoms of urinary tract eventuallyNonspecificlethargy, decreased feeding, increased sleep, vomiting, loose stools, and abdominal pain High grade fever

DIFFERENTIAL DIAGNOSISEmergent Management of Pediatric Patients with FeverFever in the Neonate and Young ChildNephrolithiasisPediatric AppendicitisPediatric Gastroenteritis in Emergency MedicinePinwormsUrinary ObstructionVaginitisVulvovaginitisGold standart for diagnoseUrine cultureAntibioticsSymptomaticChief complaint : FeverFPW, a 2 years and 3 months old male, 8 kg, 74 cm, was admitted with chief complaint of fever since 2 weeks ago. Fever was decreased by medication but increased 6 hours later. Pale (+) since a week ago. Bleeding and history of bleeding (-), history of cough (+), history of rainy nose (+), history of nausea and vomiting (-), history of diarrhea (-), history of unclear urine (+) since 4 weeks ago, the urine was like white milk (pyuria) was found since 4 weeks ago, followed by discomfort and unsatisfied micturition. Stool was normal. History of Pregnancy: Patient was second child. The mother was twenty nine years old when pregnancy. History of Birth: Aterm (39 weeks), spontaneous birth with help of midwife. Birth weight was 2500 gr and birth length was 37 cm.History of Immunization : BCG, Hepatitis B I and II, Polio I, DPT I and II, Measles.Feeding History: From birth to 18 months : Breast milk onlyCase ReportGeneralized StatusBW/BL: 8 kg/74 cmBW/A, BL/A, and BW/BL: ZS < -3

Presence StatusSensorium: GCS 15 (E4V5M6) Compos Mentis, Temperature: 37,2 C. Pale (+), Icteric (-), Dyspnea (+), Cyanosis (-), Edema (-)

Localized StatusHead: Eye: light reflex (+/+), isochoric pupil, There was inferior conjunctiva palpebra pale. Ear/Mouth/Nose: within normal limit. Thorax:Symmetrical fusiform, retraction found at epigastric intercostal (Kussmaull breathing),HR: 116 bpm, regular, no murmur RR: 40 x/minute, regular, crackles and wheezing was not found in both lung fields. Abdomen: Soepel, liver and spleen was not palpable, peristaltic (+) normalExtremities: Pulse 116 bpm, regular, adequate pressure/volume, warm on plantar and palmar, CRT < 3, Pitting edema (-), SaO2 : 94-96%, BP: 90/50mmHgUrogenital: Male: scrotum, penis, anus were found.TestResultUnitReferenceComplete Blood Count (CBC)Hemoglobin9,2G%10,7-17,1Leucocyte18,470103/mm36,0-17,5Hematocrit17,3%38-52Thrombocyte 820103/mm3217-497White Blood Cell Count Neutrophil53,5%37-80Lymphocyte27,9%20-40Monocyte18,1%2-8Eosinophil0,1%1-6Basophil0,4%0-1TestResultUnitReferralArterial Blood Gas AnalysispH7,047-7,35-7,45pCO213,4mmHg38-42pO295,5mmHg85-100HCO33,6mmHg22-26Total CO24mmHg19-25BE-24,9mmHg(-2) +2Sa0299%95-100Carbohydrate MetabolismRandom Blood Glucose122,4mg/dL< 200ElectrolyteCalcium (Ca)8,8mg/Dl8,4-10,8Natrium (N)135mEq/L135-155Kalium (K)4,0mEq/L3,6-5,5Cloride (Cl)109mEq/L96-106Creatinin : 3,67GFR : 11,09Procalcitonin : 78,72Anion Gap : 135 ( 109 + 3,6 ) = 22,4Diagnose : dd/ Urinary tract infection, Chronic pyelonephritis, Chronic glomerulonephritis + Anaemia ec dd/ Chronic disease, Fe deficiency + metabolic acidosisTherapy: bed rest Inj. Ampicillin 400 mg / 6 hrs IV Inj. Ceftriaxone 400 mg/12hrsIV Paracetamol Syrup 3 x cthFluid balance / 6 hoursFollow up Vital signDiagnostic Planning:Complete Blood Count (CBC), Arterial Blood Gas Analysis (AGDA), electrolyte DipstickUrinary cultureUrinary tract ultra-sonographyFollow up (25th Mei 2015)SFever (-) T: 37,0oCOPresence StatusSens.: GCS 15, CM, T: 37,0 C. Pale (+), Icteric (-), Dyspnea (-), Cyanosis (-), Edema (-)Localized StatusHead: There was inferior conjunctiva palpebra pale. Thorax: Symmetrical fusiform, retraction (-)HR: 116 bpm, reg, murmur (-), RR: 40 x/minute, reg, crackles and wheezing (-)Abdomen: within normal limitExtremities: Pulse 116 bpm, reg, adequate pressure/volume, warm on plantar and palmar, CRT < 3, Pitting edema (-), SaO2 : 94-96%, BP: 90/50mmHgUrogenital: Male: scrotum, penis, anus were found.Add/ Urinary tract infection, Chronic pyelonephritis, Chronic glomerulonephritis + Anaemia ec dd/ Chronic disease, Fe deficiency + metabolic acidosisPbed rest Inj. Ampicillin 400 mg / 6 hrs IV Inj. Ceftriaxone 400 mg/12hrsIV Paracetamol Syrup 3 x cthPlanning: Kidney ultra-sonography, chest x ray, arterial blood gas analysis, electrolyteLabs result: Hb/Ht/L/Plt: 6,4/19,8/16400/587000. random blood glucose: 110 mg/dLpH/pCO2/pO2/HCO3/TCO2/BE/ SaO2: 7,332/15,7/97,7/8,1/8,6/14,7/99,5%Dipstick: leu/nit/uro/pro/pH/blo/SG/ket/bil/glu: +++/-/-/++/6,5/+++/1,005/-/-/-Follow up (26th Mei 2015)SFever (-) T: 37,2oCOPresence StatusSens.: GCS 15, CM, T: 37,2 C. Pale (-), Icteric (-), Dyspnea (-), Cyanosis (-), Edema (-)Localized StatusHead: There was inferior conjunctiva palpebra pale. Thorax: Symmetrical fusiform, retraction (-)HR: 116 bpm, reg, murmur (-), RR: 24 x/minute, reg, crackles and wheezing (-)Abdomen: within normal limitExtremities: Pulse 116 bpm, reg, adequate pressure/volume, warm on plantar and palmar, CRT < 3, Pitting edema (-), BP: 110/80mmHgUrogenital: Male: scrotum, penis, anus were found.Add/ Urinary tract infection, Chronic pyelonephritis, Chronic glomerulonephritis + Anaemia ec dd/ Chronic disease, Fe deficiencyPbed rest Inj. Ampicillin 400 mg / 6 hrs IV Inj. Ceftriaxone 400 mg/12hrsIV Paracetamol Syrup 3 x cthLabs result: Urinary culture: aerobic bacteria Staphylococcus aureus, cefoxitin resistant, screening test (+) MRSA, sensitive: nitrofurantoin, tigecycline, tetracyclineDipstick: leu/nit/uro/pro/pH/blo/SG/ket/bil/glu: +++/-/-/++/6,5/+++/1,005/-/-/-Follow up (28th Mei 2015)SFever (-) T: 37,2oCOPresence StatusSens.: GCS 15, CM, T: 37,2 C. Pale (-), Icteric (-), Dyspnea (-), Cyanosis (-), Edema (-)Localized StatusHead: There was inferior conjunctiva palpebra pale. Thorax: Symmetrical fusiform, retraction (-)HR: 112 bpm, reg, murmur (-), RR: 24 x/minute, reg, crackles and wheezing (-)Abdomen: within normal limitExtremities: Pulse 112 bpm, reg, adequate pressure/volume, warm on plantar and palmar, CRT < 3, Pitting edema (-), BP: 110/80mmHgUrogenital: Male: scrotum, penis, anus were found.Add/ Urinary tract infection ec Staphylococcus aureus + Anaemia ec dd/ Chronic disease, Fe deficiencyPbed rest Inj. Ampicillin 400 mg / 6 hrs IV Inj. Ceftriaxone 400 mg/12hrsIV Paracetamol Syrup 3 x cthDipstick: leu/nit/uro/pro/pH/blo/SG/ket/bil/glu: ++/-/-/++/6,5/+++/1,005/-/-/-DiscussionCaseTheoryMale, 2 years and 3 months oldIn children aged 1-5 years, the annual incidence of UTI is 0,9-1,4% for girls and 0,1-0,2% for boysChief complaint of fever since 2 weeks ago. Pale (+) since a week ago. History of unclear urine (+) since 4 weeks ago, the urine was like white milk (pyuria) was found since 4 weeks ago, followed by discomfort and unsatisfied micturition. Fever remains a more common presentation in the neonates, infants, and younger children whereas older children present with other symptoms. 80% of the fever > 38oC.Dysuria, frequency,, new onset incontinence, flank pain can also be the main symptom of UTI in younger children.Hb decrease: 9,2Leucocyte increase: 18.470Ht decrease: 7,3Platelet increase: 820.000Creatinin: 3,67Procalcitonin: 78,72AGDA: metabolic acidosis When the child appears sick, a CBC, CRP, blood culture, and procalcitonin should be obtained to evaluate for sepsis. Blood culture is usually done for sick-looking children.Elevation of serum procalcitonin is reported to correlate with pyelonefritis and to predict risk of renal scarring and maybe particularly useful in infants. DiscussionCaseTheoryTherapy: bed rest Inj. Ampicillin 400 mg / 6 hrs IV Inj. Ceftriaxone 400 mg/12hrsIV Paracetamol Syrup 3 x cthFluid balance / 6 hoursFollow up Vital signFirst-line agents include amoxicillin, TMP-SMX, nitrofurantoin, and cephalosporin. Total duration of therapy should be 7-14 daysUrinary culture: Aerobic bacteria Staphylococcus aureus, cefoxitin resistant, screening test (+) MRSA, sensitive: nitrofurantoin, tigecycline, tetracyclineDipstick: leu/nit: +++/-Common pathogens causing UTI include Pseudomonas and Staphylococcus aureus.Nitrite are generated form the breakdown of dietary nitrate by bacteria and leucocyte esterase is the breakdown product of white cells.Thank You