Unusual and missed case of Streptococcal Pharyngitis presenting as membranoproliferative Glomerulonephritis; case report

Streptococcal pharyngitis is common in the pediatric age group. Although its treatment is simply achieved by administration of a single dose of benzathine penicillin, oral penicillin for 10 days, or azithromycin for 5 days, it has serious complications such as rheumatic fever [RF] and chorea if left untreated. Treatment of pharyngitis does not prevent glomerulonephritis but prevents the spread of streptococci that can cause an epidemic in glomerulonephritis if they are of the nephritogenic strain. Post Streptococcal Glomerulonephritis [PSGN] is common in school age children and usually has a benign course as more than 95 percent of the cases recover the acute phase and less than 5 percent progress in their course to Rapidly Progressive Glomerulonephritis [RPGN] and ultimately about one percent develop End Stage Renal Failure [ESRF]. Herein, we present a 12-year-old male with a history of untreated streptococcal pharyngitis who first came to our clinic with a history of arthralgia and arthritis, fatigue, hematuria, petechia, purpura, elevated levels of Blood Urea Nitrogen [BUN] and Creatinine [Cr], and low grade fever. Echocardiography revealed endocarditis which was treated. However, renal failure required renal replacement therapy [RRT], and massive proteinuria needed renal biopsy which revealed membrano proliferative glomerulonephritis [MPGN]

sensitivity of ultrasonography in detecting renal cortical defects in pyelonephritic patients with or without vesicoureteral reflux

The presence of renal scarring has been documented in 5% to 15% of febrile urinary tract infections. The main aim of this study was to compare the value of renal ultrasonography and cortical scintigraphy with technetium-99m dimercaptosuccinic acid [DMSA] in detecting renal cortical defects in acute pyelonephritis. Between June 2003 and February 2012 a prospective cohort study of patients aged 1 month to 14 years of age was conducted. Pediatric patients with documented urinary tract infections were evaluated with renal ultrasonography, voiding cystoureterography [VCUG] and DMSA scintigraphy. Statistical test was two-tailed and was considered significant when P< 0.05. The results of DMSA scans showed 70.2% of cases as being abnormal. Renal ultrasonographies were reported to be normal in 72.45 and showed mild hydronephrosis in 37.7% of cases, moderate to severe hydronephrosis in 40.62%, stone formation in 13.66% and scar formation or decreased cortical thickness in 8.2%. There was a significant difference in ultrasonography reports between patients with normal and abnormal DMSA scans [P< 0.012] but there was no significant difference in detection of scar formation between DMSA scan results and those of ultrasonography in our patients. Among patients with severe abnormalities on DMSA scintigraphy the percent of cases with vesicoureteral reflux was significantly higher than those with normal scans or mild to moderate changes on DMSA scintigraphy. [46.3% vs 26.9%]. We concluded that ultrasonography is a sensitive method for detection of renal cortical defects and ultrasonography can also predict the presence of vesicoureteral reflux in pyelonephritic patients

Biochemical risk factors for stone formation in healthy school children

Prevalence of urolithiasis in childhood is increasing. The wide geographic variation in the incidence of lithiasis in childhood is related to climatic, dietary, and socioeconomic factors. Many children with stone disease have a metabolic abnormality. In Southeast Asia, urinary calculi are endemic and are related to dietary factors. The main aim of this study was to determine the prevalence of renal stone, urine metabolic abnormality, control of blood pressure and demographic character in elementary school children of Qom. A cross sectional study was performed on 110 primary school children [56 girls and 54 boys] aged 7 to 11 years old. Demographic data such as age, height, weight were gathered, and systolic and diastolic blood pressure, Urine analysis and culture, urinary levels of calcium, creatinine, phosphorus, magnesium, sodium, potassium, uric acid, cystine, citrate, oxalate, protein and sonographic findings were evaluated. The mean [ +/- SD] of age was 8.85 +/- 1.51 years. Only one child had renal stone [1%], but the prevalence of abnormal renal sonography was 7%. The most prevalent urine metabolic abnormalities were hypercalciuria [23%] and hypocitraturia [100%]. 11.2% of children had positive urine culture that all were female. The prevalence of high blood pressure was 7.1% for girls and 11.1% for boys. The prevalence of renal stone in children in this study was 1%, which means the accurate judgment about the prevalence of renal stone in Qom city needs more comprehensive studies. Similar to other studies in Iran this study shows that the prevalence of hypercalciuria is significantly higher comparing to other countries, it may be associated with excessive intake of sodium

[Diagnostic value of Procalcitonin in detection of acute pyelonephritis in children]

In the absence of specific symptomology in children, the early diagnosis of acute pyelonephritis is a challenge, particularly during infancy. This study was performed to evaluate the diagnostic utility of serum procalcitonin levels in children with acute pyelonephritis. Serum procalcitonin was measured with a rapid, semi-quantitative immune-chromatographic test in 56 children who presented with symptoms of UTI; a level >0.5 ng/mL was considered abnormally elevated. A DMSA scan was done on all cases and the procalcitonin levels were compared with the DMSA study; positive and negative predictive values, [ppv and npv], were determined. The procalcitonin test was positive in 43 of the 49 patients with a positive DMSA scan; p.p.v. of the procalcitonin test was 95.3%; n.p.v was 38.5%. Procalcitonin test may be utilized as a sensitive marker for early diagnosis of acute pyelonephritis

Distal renal tubular acidosis and its relationship with hearing loss in children: preliminary report

In autosomal recessive distal renal tubular acidosis [DRTA], a substantial fraction of the patients have progressive bilateral sensorineural hearing loss. This coexistence is due to the mutations of a gene expressed both in the kidney and in the cochlea. The aim of this study was to assess the correlation between hearing loss and DRTA. In this study, 51 children diagnosed with renal tubular acidosis were evaluated. Diagnosis of DRTA was based on clinical manifestations and detection of normal anion gap metabolic acidosis, urine pH higher than 5.5, and positive urinary anion gap. Audiometry was performed in children with DRTA and sequencing of the ATP6V1B1 gene was done for those with sensorineural hearing loss. Twenty-seven patients [52.9%] had DRTA, of whom 51.9% were younger than 1 year old, 55.6% were boys, and 44.4% were girls. Eleven patients [40.7%] had bilateral sensorineural hearing loss, consisting of 5 of 15 boys [33.3%] and 6 of 12 girls [50.0%]. There was no correlation between hearing loss and gender. Three patients with hearing loss had mutation in the ATP6V1B1 gene [11.1% of patients with DRTA and 27.3% of patients with DRTA and hearing loss]. This study indicated that a significant percentage of the children with DRTA had sensorineural hearing loss and mutation in ATP6V1B1 gene. It is recommended to investigate hearing impairment in all children with DRTA

Diagnostic potential of urinary tumor necrosis factor-alpha in children with acute pyelonephritis

Tumor necrosis factor-alpha [TNF-alpha] is an important mediator of the inflammatory response in serious bacterial infections. The aim of this study was to evaluate the potential of urinary TNF-alpha for diagnosis of acute pyelonephritis in children. This study was conducted from March 2006 to December 2007 on children with confirmed diagnosis of acute pyelonephritis. They all had positive renal scintigraphy scans for pyelonephritis and leukocyturia. The ratios of urinary TNF-alpha to urine creatinine level were determined and compared in patients before and after antibiotic therapy. Eighty-two children [13 boys and 69 girls] with acute pyelonephritis were evaluated. The mean pretreatment ratio of urinary TNF-alpha to urinary creatinine level was higher than that 3 days after starting on empirical treatment [P = .03]. The sensitivity of this parameter was 91% for diagnosis of acute pyelonephritis when compared with demercaptosuccinic acid renal scintigraphy as gold standard. Based on our findings in children, the level of urinary TNF-alpha-creatinine ratio is acute increased in pyelonephritis and it decreases after appropriate therapy with a high sensitivity for early diagnosis of the disease. Further research is warranted for shedding light on the potential diagnostic role of urinary TNF-alpha in pyelonephritis in children

Urinary N-acetyl-beta-D-glucosaminidase as a diagnostic marker of acute pyelonephritis in children

Prompt diagnosis and localization of pyelonephritis are of great importance in children. The urinary excretion of enzymes, and in particular N-acetyl-beta-D-glucosaminidase [NAG], is considered a simple noninvasive marker for detection of renal tubular dysfunction due to pyelonephritis. This study was performed to determine the diagnostic value of urinary NAG in acute pyelonephritis. In a quasi-experimental study conducted on 72 children with confirmed pyelonephritis, we measured urinary NAG, creatinine, and NAG-creatinine ratio before and after the treatment. Diagnostic values of these parameters were evaluated by considering the patients before and after the treatment as disease-positive and disease-negative groups, respectively. The patients were 18 boys [25.0%] and 54 girls [75.0%] with a mean age of 43.0 +/- 39.0 months. The mean levels of urinary NAG were 12.20 +/- 6.14 U/L and 5.46 +/- 7.98 U/L before and after the treatment, respectively [P < .001]. The sensitivity and specificity of urinary NAG-creatinine ratio for diagnosis of pyelonephritis were 73.6% and 77.3%, respectively, with a cutoff point of 10.16 U/g [area under the curve = 0.76, 95% confidence interval, 0.67 to 0.76]. Significantly higher levels of urinary NAG were found in those who had a negative urine culture at diagnosis [8.8 +/- 10.4 U/L] compared to those with a positive urine culture [4.5 +/- 8.7 U/L]. We concluded that urinary NAG is elevated in children with pyelonephritis and it can be considered as a further criterion in the diagnosis of upper urinary tract infection

Urinary lnterleukin-8 in acute pyelonephritis of children: a before-after study

The aim of this study was to assess urinary interleukin-8 [IL-8] levels in pyelonephritis and its relation with the clinical course of the infection and of inflammatory changes detected by renal scintigraphy. In this quasi-experimental before-after study, we evaluated 91 children aged 1 to 144 months [mean 34.4 +/- 35.2 months] with pyelonephritis. Inflammatory markers including erythrocyte sedimentation rate, C-reactive protein, leukocyte count, and urinary IL-8, together with the results of ultrasonography, voiding cystourethrography, and dimercaptosuccinic acid renal scintigraphy were evaluated in these children. The ratios of urinary IL-8 to creatinine [IL-8/C] before and after the treatment were compared with each other. Urinary IL-8/C levels were significantly higher after the empirical treatment in comparison with those before the treatment [0.19 +/- 0.21 versus 0.51 +/- 0.53, P < .001]. No correlation was found between the urinary IL-8 levels and leukocyturia, urine culture results, other inflammatory markers, or findings of imaging examinations. We found high urinary IL-8 levels in children with pyelonephritis. We also documented its increasing after the treatment. We conclude that evaluation of urinary IL-8 can be a noninvasive test for diagnosis of upper urinary tract infection and its response to treatment

Antimicrobial resistance pattern in urinary tract infections in children on continuous ambulatory peritoneal dialysis

Growing antibiotic resistance demands the constant reassessment of antimicrobial efficacy, particularly in countries with wide antibiotic abuse. Knowledge of resistance trends is particularly important when prescribing antibiotics empirically, as is usually the case for urinary tract infections [UTIs] especially in children with terminal renal failure on continuous ambulatory peritoneal dialysis [CAPD] treatment. The aim of this study was to analyze the resistance of bacterial isolates to commonly used antibiotics in such patients. In this study, bacterial isolates were evaluated from urine samples collected from pediatric patients [6 months to 17 years] on CAPD with acute UTIs in Tehran from March 2006 through September 2006. Sensitivity was measured by disc diffusion method using NCCLS protocol. The most prevalent urinary pathogen was Escherichia coli from 27 cases [75%]. In general, the lowest resistance rate of microorganisms was against amikacin [3.7%] and the highest resistance rate was against amoxicillin [70.4%].A comparison of these data with those of other countries showed that there was considerable geographic variation in bacterial patterns of sensitivity and resistance properties. Therefore, the selection of antibiotics for empiric therapy especially in children with terminal renal failure on continuous ambulatory peritoneal dialysis [CAPD] treatment should be based on the knowledge of the local conditions

Fungal peritonitis in Iranian children on continuous ambulatory peritoneal dialysis

Fungal peritonitis [FP], causing catheter obstruction, dialysis failure, and peritoneal dysfunction, is a rare but serious complication of peritoneal dialysis. In this study, the frequency and risk factors of FP are evaluated in children who underwent peritoneal dialysis. A retrospective multicenter study was performed at the 5 pediatric peritoneal dialysis centers in Iran from 1971 to 2006, and FP episodes among 93 children were reviewed. Risk ratios were calculated for the clinical and demographic variables to determine the risk factors of FP. Ninety-three children aged 39 months on average were included in study. Sixteen out of 155 episodes of peritonitis were fungi infections, all by Candida albicans. The risk of FP was higher in those with relapsing bacterial peritonitis [P = .009]. Also, all of the patients had received antibiotics within the 1 month prior to the development of FP. Catheters were removed in all patients after 1 to 7 days of developing FP. Six out of 12 patients had catheter obstruction and peritoneal loss after the treatment and 5 died due to infection. Fungal peritonitis, accompanied by high morbidity and mortality in children should be reduced by prevention of bacterial peritonitis. Early removal of catheter after recognition of FP should be considered

Isolation of mycobacterium and other microorganism from skin infectious in children during Bam earthquake

The Bam earthquake in southeastern Iran turned an ancient city to dust, killing thousands and destroying 80% of all infrastructures. More than 30,000 people died and It left some 100,000 people homeless. Direct contact with polluted water increases the risk of infection, particularly wound infections, cellulitis, dermatitis, conjunctivitis, and ear, nose and throat infections. The prevalence of NTM [non-tuberculosis mycobacteria] is difficult to obtain. The aim of this study was isolation of bacteria and mycobacterial agents, especially atypical species from dermal lesions of children in Bam earthquake. In this descriptive study, 88 children settled in camps in 2004 were enrolled. Samples from dermal lesions of children were obtained and transported with middle brook 7H9 and Brain Heart [BH] media to laboratory for isolation of mycobacterial agents and other bacteria. For isolation of mycobacterium, after decontamination and acid-fast staining, they had been cultured in Lewenstein-Jensen medium. Having isolated mycobacteria by differential tests their antibiotic resistance and susceptibility were studied. Meanwhile, other bacteria were identified by staining and culturing in standard media. The study population included 32 girls and 56 boys. Of 88 samples, 3 mycobacteria were isolated [3.4%] of which 2 were M. chelonae [rapidly growing] and 1 was M. scrofulaceum [slowly growing]. The most common isolated bacteria were E.coli [41%] and Coagulase negative staphylococcous [38%].Infectious disease epidemics may play a role in the post disaster period. Since atypical mycobacteria exist in soil, and some cases were reported from Iran, isolation of these microorganisms is of utmost importance especially in children after a disaster such as earthquake

[Antibiotic susceptibility patterns in H. influenzae type B isolated from healthy children oropharynx in day care centers of Tehran]

Haemophilus influenzae type b [Hib] is a most frequent cause of invasive diseases such as meningitis, septic arthritis and pneumonia in children under 5 years old. Asymptomatic oropharyngeal colonization is an origin of distribution of microorganism to others and probable bacteremia in the same child. The aim of this study was to determine antibiotic susceptibility of Hib in Tehran day care centers. Hib was isolated from oropharynx of 1000 children visiting 25 day care centers selected randomly in different parts of Tehran city during second half of year 2005. For antibiotic susceptibility determination we used disk diffusion test. Ampicillin resistance was 32.3% and Beta lactamase production was seen in 23.6%. Cephalosporins resistance except for cefixime was between 10% to 20% and in cefixime was 58.8%. Rifampin resistance was 17.6%. Resistance to studied macrolids including azythromycin and clarythromycin was 19.6% and 35.3%. On the base of high antibiotic resistance to Hib in our study and other similar studies in Iran, we recommend to use optimal effective and proper antibiotics to decrease the high rate of antibiotics resistance to Hib colonization and its invasive diseases

Beta 2 microglubulin as a marker for vesicouretral reflux in children

Reflux nephropathy is one of the main causes of advanced renal failure in children the world over. Vesicoureteral reflux [VUR] is seen in 1.8% of the children; however; its prevalence is 34% in children suffering from urinary tract infections [UTI] and 40% in their siblings. The current study was carried out to evaluate the potential of replacing cystography [which requires exposure to radiation] by measuring urinary levels of beta[2]-microglubolin in screening reflux. The urine samples of 83 children undergoing cystography were assessed for beta[2]-microglubolin/creatinine [beta[2MG/Cr] ratio]. There were 47 children suffering from VUR and 36 healthy children [55 girls and 28 boys]. The urine samples were obtained during voiding cysto-urethrography [VCUG] and were evaluated for beta[2]-microglubolin and creatinine. VUR was classified based on WHO classification and beta[2]-micro-glubolin was reported in microgram to milligram of creatinine. Measurement of beta[2]-microglubolin was performed using 96-test beta[2]MG radioimmunoassay kit and creatinine by spectrophotometry using autoanalyzer. The mean beta[2MG/Cr] ratio was significantly higher in children with VUR [7.9 7 +/- 3.45] than the children without VUR [0.24 +/- 0.23] [P=0.01]. The mean beta[2MG/Cr] ratio in children with reflux grades 4 and 5 [12.01 +/- 8.93] was significantly higher than children with VUR of lower grades [3.04 +/- 0.81] [P=0.02]. The maximum beta[2MG/Cr] ratio [23.3] was seen in a patient with VUR of grade 4 while the minimum of it [0] was observed in patients without reflux. The difference between/32MG/Cr ratio in the patients without reflux and the patients with lower grades of VUR [1-3] was not significant. The maximum/32MG/Cr ratio was 0.85 in patients without reflux. The maximum beta[2MG/Cr] ratio was 0.85 in patients without reflux. This ratio can be assumed as the cutoff point for reflux screening. This study revealed that patients with grades 4 and 5 reflux have significantly higher beta[2MG/Cr] ratios than patients without reflux or with lower degrees of reflux. Renal failure was very soon observed in 2 children with the highest amounts of beta[2MG/Cr] suggesting that a simple urine test may demonstrate the prognosis. It is recommended to study the relationship between beta[2MG/Cr] and renal scars

Interleukins 1 and 6 in children with acute pyelonephritis

Renal infection and scarring are the leading causes of end stage renal disease [ESRD] in some parts of the world [e.g. Iran]. Urinary interleukins [IL] 1 and 6 have been reported to be high in acute pyelonephritis in previous studies. This study was performed to determine the relation between IL 1 and 6 levels in the presence of acute pyelonephritis and the relation between the amount of these cytokines and the severity of pyelonephritis by dimercaptosuccinic acid [DMSA] scan. Children ages 1 month to 12 years who were admitted to the nephrology ward of Mofid Children's Hospital for pyelonephritis from January to July 2004 were enrolled in the study. Interleukins 1 and 6 and creatinine were measured in 80 random urine samples of 37 patients [81%female] with acute pyelonephritis and 43 healthy children [81% female]. Urinary cytokines were measured by Enzyme Linked Immunosorbent Assay [ELISA] and creatinine by spectrophotometry methods and recorded in microgram per mg of creatinine. Pyelonephritis was confirmed by positive urine culture and/or DMSA scan in all patients using SPECT apparatus. Data were analyzed by paired student t test and differences considered significant if p<0.05. Mean interleukin 1/creatinine [IL 1/Cr] ratio in patients with pyelonephritis was 0.70 +/- 0.96 [range 0.02-5.08] and in healthy children was 0.04 +/- 0.12 [range 0-0.51]. Mean interleukin 6/creatinine [IL 6/Cr] ratio in patients with pyelonephritis was 4.80 +/- 10.06 [range 0.01-44.74] and in healthy children was 0.15 +/- 0.37 [range 0-2.32]. There were significantly higher levels of urinary IL-1 and IL-6 in children with pyelonephritis than healthy children, but we didn't find any significant relationship between urinary interleukin levels and other parameters such as pyuria, ESR, CRP and different grades of renal involvement in DMSA scans