Follow-up of acute pyelonephritis in children by Tc-99m DMSA scintigraphy: quantitative and qualitative assessment.

PURPOSE: The author's goal was to create a system to identify children at risk for development of progressive renal damage. METHODS: Thirty-four children were examined with Tc-99m DMSA scintigraphy in the acute stage of an initial episode of pyelonephritis, after 6 months, and again after 1 year. The scintigraphic findings were correlated with clinical and laboratory data. RESULTS: All children had parenchymal defects in the acute stage: 93% of the kidneys and 85% bilaterally. After 6 months, the defects had diminished or disappeared in 66% of the kidneys. New defects appeared in 22%. At 1 year, no further improvement was seen in the kidneys, with an improved or unchanged pattern at 6 months. New defects appeared in 34%. Mean kidney activity uptake expressed as the percentage of administered dose (KU/AD), was low in the acute stage, increased at 6 months, with no further significant increase at 1 year. Eighty-three percent of children with urine cultures growing > or = 104 bacteria/ml at follow-up had decreased KU/AD values, whereas all children with urine cultures growing < 104 bacteria/ml had increased KU/AD values. CONCLUSIONS: Quantitative assessment increases the sensitivity of Tc-99m DMSA scintigraphy. Follow-up with this method makes it possible to identify the children with decreasing renal tubular function who may be at risk for progressive renal damage. Moderate bacteruria of 104 bacteria/ml urine is associated with deterioration of renal tubular function.

Age-related reference limits for urine levels of albumin, orosomucoid, immunoglobulin G and protein HC in children.

Urine levels of albumin, orosomucoid (alias alpha1-acid glycoprotein), immunoglobulin G (IgG) and protein HC (alias alpha1-microglobulin) were determined in 247 healthy Swedish infants and children aged 1 day to 15 years. Urine samples were collected and stored in conditions known to guarantee stable protein levels. The protein levels were measured both as mass concentrations (mg l(-1)) and as protein-creatinine ratios (mg mmol(-1)). In an effort to arrive at practically useful upper reference limits, the variability with age for both units was analysed. The variability with age for the levels of three of the four proteins was considerably lower when the levels were expressed as creatinine ratios rather than as mass concentrations. The results allowed suggestion of the following upper reference limits, expressed as mg mmol(-1) creatinine, for use in clinical practise: IgG, 1 month to 15 years: 1.0; protein HC, 1 month to 15 years: 0.8; orosomucoid, 1 month to 15 years: 0.5; albumin, 1 month to 1 year: 3.8; 1-5 years: 3.3; 6-10 years: 2.7; 11-15 years: 2.1. In the immediate neonatal period the urine levels of all proteins were high and very variable.

Pediatric urinary tract reconstruction using intestine.

OBJECTIVE: To analyse the outcome of urinary tract reconstruction in children. MATERIAL AND METHODS: Fifteen children with bladder exstrophy or neurogenic bladder, 4-18 years old, were followed in accordance with a predetermined program for bladder augmentation (13 pat) or continent urinary reservoir (2 pat). The follow-up time was 1.7-6.3 years, median 3.7 years. RESULTS: All were dry, though one case had occasional leaks. Three bladder neck reconstructions, two artificial sphincters, one sling plasty and one fistula closure with subsequent bladder neck injection were required. Bladder volumes were adequate for age at low pressures. Reflux resolved in 12/13 ureters. A boy with preoperative renal insufficiency was transplanted. Total renal function remained otherwise stable despite acidosis in one case and some glomerular impairment in all. Progressive parenchymal lesions were seen in combination with abundant mucus, infections and calculi only. Growth and bowel function was unaffected. Bone mineral density showed overall increase; some low values were not consistent between investigations. CONCLUSIONS: Urinary tract reconstruction in children results in continence and regression of reflux. Growth, bone mineralization and renal function are unimpaired during the first years, but irrigation of the bladder is essential to minimize the risk of urinary tract infection. However, glomerular function might be affected and the possible risk of metabolic complications in later life can only be determined by continuous close monitoring over an extended period of time. ABBREVIATIONS: Voiding cystourethrogram (VCUG), dimercapto-succinic acid (DMSA), Chrome51-Ethylenediaminetetraacetic acid (Cr-EDTA), single photon absorption (SPA), bone mineral content (BMC), bone mineral density (BMD), dual photon x-ray absorption (DEXA), glomerular filtration rate (GFR), urinary tract infection (UTI), immunoglobulin G (IgG), clean intermittent catheterization (CIC) and subureteral teflon injection (STING).

Serum cystatin C as a determinant of glomerular filtration rate in children.

The serum levels of cystatin C and creatinine were determined in a population comprising 69 children, 1-16 years old, and including children with both normal and reduced glomerular filtration rate (GFR) as determined by Cr-EDTA clearance measurement. The overall correlation between the reciprocal cystatin C concentration and GFR was significantly stronger (p < 0.05) than that between the reciprocal creatinine concentration and GFR and this was true also for the subpopulation of children with reduced GFR. Receiver-operating characteristic analysis also indicated superior diagnostic accuracy of serum cystatin C compared to that of serum creatinine for reduced GFR. The serum cystatin C reference values (mean +/- 1.96 SD) determined for children over one year of age was 0.63-1.33 mg/l, which is similar to that previously determined for adults. Serum cystatin C appears to be an attractive alternative to creatinine for estimation of GFR not only in adults, but also in children.

Kidney swelling. Findings on DMSA scintigraphy.

OBJECTIVE: To develop criteria identifying swollen kidneys on dimercaptosuccinic acid (DMSA) renal scintigraphy in acute pyelonephritis with regard to the DMSA distribution pattern, kidney functional size, and radioactive uptake. SUBJECTS AND METHODS: Thirty-eight children aged 15 days to 7 years with known pyelonephritis were examined with DMSA renal scintigraphy. All children were observed 2 or 3 times. In total, 94 scintigrams were evaluated. Qualitative and quantitative criteria for swelling were defined. RESULTS: Thirty-one observed kidneys satisfied the criteria of swelling. Quantitatively, kidney length and width/length were greater in swollen kidneys. Kidney uptake in percent of injected dose and kidney uptake/background were lower in swollen kidneys. Qualitatively, focal radioactive uptake defects known from a previous examination were sometimes obscured by swelling, and reappeared at follow-up. In 5 children with signs of swelling on repeat imaging, scintigraphy reinfection at the time of swelling was verified. CONCLUSIONS: Swollen kidneys may be the only sign of acute pyelonephritis on DMSA scintigraphy and swelling may obscure focal radioactive uptake defects. Measurement of kidney size and radioactive uptake can help identify swollen kidneys at DMSA scintigraphy and disclose acute pyelonephritis in the absence of overt clinical symptoms.

Ovarian stromal hypertrophy in hyperandrogenic women.

OBJECTIVE: By using vaginal endosonography, ovarian stromal hypertrophy has been shown to be a strong diagnostic feature of polycystic ovarian syndrome and related states. However, this sign is difficult to quantify and to correlate with other findings because of its subjectivity. We have evaluated the use of computer assisted analysis of ultrasound scans to provide more objective measurements of ovarian structure and size. DESIGN: We used a computer assisted method for the reading of ultrasound scans. It allowed selective calculation of the stromal area by subtraction of the cyst area from the total ovarian area on a longitudinal ovarian section. PATIENTS: A consecutive series of 57 patients with hyperandrogenism (group 1), 17 patients with hypothalamic anovulation (group 2) and 20 normal women (group 3). RESULTS: By computerized measure, 75% patients from group 1 had a bilateral stromal area above the mean +2 SD (700 mm2) of women from group 3. All patients from group 2 were below this threshold. Serum LH level was above the normal range in 45% patients from group 1. The stromal area correlated positively with the serum delta 4-androstenedione (r = 0.47, P < 0.005) and 17 alpha-hydroxyprogesterone (r = 0.39, P < 0.005) levels, exclusively in group 1. It did not correlate with the basal serum testosterone, LH or insulin levels. The cyst area did not correlate with any hormonal parameter. CONCLUSION: Ovarian stromal hypertrophy is a frequent and specific feature of hyperandrogenism. It correlates with the ovarian androgenic dysfunction. Its presence is not always linked with elevated serum immunoreactive LH levels. Further data are needed to elucidate the role of insulin and ovarian growth factors.

A simple reliable agglutination test for screening P-fimbriated Escherichia coli in children with urinary tract infections gives valuable clinical information.

Most urinary tract infections (UTI) are caused by Escherichia coli (E. coli) and the pathogenetic mechanisms of this bacterium have been thoroughly studied. Lipopolysaccharide (LPS), capsular polysaccharides and fimbrial structures are among the more important virulence markers. P-fimbriae, with a specificity for the carbohydrate structure of the P blood group system (alpha-D-Gal-1,4-beta-D-Gal) have attracted particular interest, as non-fimbriated E. coli rarely give rise to pyelonephritis, unless the normal defence mechanisms of the urinary tract are impaired. We have evaluated a commercial test (Orion Diagnostica, PF test), developed to detect P-fimbriae on E. coli from clinical isolates. It is based on latex particles with covalently bound receptors (alpha-D-Gal-1,4-beta-D-gal). In this study a high correlation was found between pyelonephritis, as judged by clinical and biochemical criteria, and a positive PF test.

Early pregnancy varicella and associated congenital anomalies.

A case of congenital anomalies following varicella infection in the 8th week of gestation is described. Though the baby demonstrated a majority of the features characteristic of the congenital varicella syndrome and had positive immunofluorescent and ELISA tests for VZ specific antibodies, no vesicles or depigmented skin areas were seen.

Primary nephrotic syndrome in Arab children in Kuwait.

Fifty-five Arab children with primary nephrotic syndrome (PNS) were seen at two regional hospitals in Kuwait over a 5-year period. There were 35 boys and 20 girls with a mean age of 5.3 years. The annual incidence was 7.2 and 6.0 per 100,000 children below 10 and 12 years of age, respectively. An initial response to steroids was noted in 84% with almost 50% responding within 1 week of therapy. Nine patients did not respond to steroids; histopathological classification of their renal biopsies showed 5 cases of membranoproliferative nephritis, 3 cases of focal segmental glomerulosclerosis and 1 case of membranous nephropathy. Microscopic haematuria was noted at presentation in 7 of 46 steroid responders, in all 5 patients with membranoproliferative disease and in 1 of 3 with focal segmental glomerulosclerosis. We conclude that the incidence of PNS seems to be higher among Arab children than in Western countries. With regard to initial biochemical abnormalities, steroid response and subsequent relapses, the pattern is the same as elsewhere.

A multicenter therapeutic study of 1100 children with brucellosis.

A 6-year multicenter therapeutic study was performed on 1100 children with brucellosis in order to compare several antibiotic combinations and duration of treatment. The patients were randomized to receive oral therapy with oxytetracycline, doxycycline, rifampin and trimethoprim-sulfamethoxazole (TMP/SMX) either alone or in combination with each other or combined with streptomycin or gentamicin injections. The patients were also randomized into three groups based on the duration of oral therapy: 500 patients were treated for 3 weeks; 350 for 5 weeks; and 250 for 8 weeks. When intramuscular aminoglycosides were used, streptomycin was given for 2 weeks and gentamicin for 5 days. In oral monotherapy oxytetracycline, doxycycline and rifampin showed comparable results with low relapse rates (less than or equal to 9%) and no statistically significant differences were found among 3-, 5- or 8-week durations of therapy. TMP/SMX alone showed an unacceptably high relapse rate (30%) with all durations of therapy. In combined oral therapy rifampin plus oxytetracycline, rifampin plus TMP/SMX and oxytetracycline plus TMP/SMX showed comparable results with low relapse rates ranging from 4 to 8% in patients receiving therapy for 3 or 5 weeks, no relapses occurred in patients treated for 8 weeks. When oral monotherapy was combined with either streptomycin or gentamicin, very few relapses were seen, irrespective of the duration of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Probable transmission of brucellosis from breast milk to a newborn.

The first case of neonatal brucellosis is described. The baby was fed breast milk only when the mother became acutely ill with fever, arthralgia and malaise. At the same time the baby was febrile. Blood cultures grew Brucella melitensis in both mother and child. The brucella agglutination titre in the breast milk was 1:2560. Both mother and child recovered during treatment with streptomycin.

Outbreak of coxsackievirus A-14 meningitis among newborns in a maternity hospital ward.

During the late winter of 1983, 16 newborns with vague symptoms of failure to thrive, reluctance to feed and a slight rise in body temperature, were found to have meningitis caused by Coxsackievirus A-14. The cerebrospinal fluid showed pleocytosis with polymorphonuclear cells in excess but was otherwise normal. The clinical course was uneventful in all infants, but two of them demonstrated clinical signs of incipient cerebral oedema during the acute phase of the illness. An electroencephalogram (EEG) during the initial course of the disease and at nine months of age was normal in all. During a follow-up period of 2 1/2 years they all developed normally and no sequelae were noted. The presentation also demonstrates the usefulness of Vero cells for the propagation of the responsible virus.

Prenatal diagnosis of urinary tract abnormalities by ultrasound.

The capacity of a general ultrasound screening program to detect fetal malformations affecting the urinary tract was evaluated in an epidemiologic study. A total of 11,986 pregnant women, representing 97% of the pregnant population in Malmö, Sweden, from April 1978 through August 1983 were examined. On routine examinations performed by midwives in the 17th and 33rd gestational weeks, the fetal anatomy was carefully surveyed. The overall frequency of fetal malformations was 0.5%, with urinary tract abnormalities representing approximately 50% of the total number. In 20 of 33 cases, the ultrasound findings were those of hydronephrosis or hydroureter. In ten cases, a cystic renal malformation was found, and the remaining three cases represented double renal pelvis, Potter syndrome, and posterior urethral valve. A total of 28 abnormalities were unilateral and five bilateral. No case of unilateral absence of renal tissue was noted prenatally. Prenatal diagnosis of urinary tract abnormalities known to precipitate neonatal urosepsis and subsequent renal scarring and other complications makes it possible to start an early antibiotic prophylaxis regimen. A complete workup of the infants can be started early and before life-threatening complications occur.

Nalidixic acid and trimethoprim/sulphamethoxazole as alternatives for short-term treatment of urinary infections.

The efficacy of 3-day therapy with nalidixic acid in 16 children, and trimethoprim/sulphamethoxazole in 19 children, was studied prospectively in children with an acute infection of the lower urinary tract and compared with that of a conventional 10-day course with the same drugs. The immediate cure rate was 97% in the 3-day group and 90% in the 10-day group. During 3 months of follow-up there were altogether six re-infections in children given short-term treatment and six in the conventionally treated group. The results give further support for the suggestion that 3-day therapy is equivalent to 10-day treatment in uncomplicated urinary infections in children and that both nalidixic acid and trimethoprim/sulphamethoxazole are good alternatives in such an approach.

Brucella arthritis in children.

A study in 50 children suffering from acute brucellosis demonstrated that acute arthritis is a common and often predominant manifestation of the disease. The patients lived in an area where brucellosis is endemic: their ages ranged from six months to 12 years. All patients had a brucella agglutination titer of greater than or equal to 1:320 on admission. The knee and hip joints were most commonly affected with symptoms and findings from only one joint predominating. Associated findings of only moderately elevated ESR and normal leucocyte counts with relative lymphocytosis in the vast majority of the cases made it fairly easy to distinguish acute brucella arthritis from septic arthritis of other origin. A positive blood culture for Brucella melitensis was obtained in 35 of the patients. Treatment with tetracyclines, trimethoprim-sulphamethoxazole, with or without combination with streptomycin, resulted in a prompt recovery in all patients. No mortality was seen. Seven patients were readmitted with reinfections during a mean follow-up period of 13 months. Two patients with a history of prolonged fever, malaise and arthralgia were found to have osteomyelitis of the adjacent bone tissue. They also recovered without sequelae.

Cardiac manifestations in brucellosis.

Cardiac involvement in childhood brucellosis is rare and when present mimics findings usually noted in acute rheumatic fever with carditis. We report five children aged 6 to 11 years. Echocardiography showed mitral valve vegetations in one, functional mitral valve incompetence in two, and sluggish myocardial function in one. All the patients presented with fever, arthralgia, and malaise, four of them had leucopenia, and all five showed relative lymphocytosis. Blood cultures grew Brucella melitensis, biotype 1 in four cases and type 2 in one. Treatment with oral tetracyclines over three weeks together with streptomycin over the first two weeks was successful in all the patients, including one in whom oral trimethoprim/sulphamethoxazole was first tried but was unsuccessful as the patient developed a relapse after two months.

Antibiogram of urinary tract isolates in Kuwait.

1253 urinary tract isolates collected during 9 months (April-December 1984) were analysed by the agar diffusion method for sensitivity to 13 antimicrobial agents commonly used for the treatment of urinary tract infections in children and adults. We noticed an agitatingly high resistance of Escherichia coli to ampicillin, sulphonamide and trimethoprim/sulphamethoxazole and of Proteus spp. to ampicillin. As Kuwait is one of the countries where the total consumption of antibiotics is very high as compared to most of the western countries, we are inclined to assume that this generous policy for the prescription of especially ampicillin and other broad spectrum antibiotics in uncomplicated infections has generated this serious consequence.

Intra-abdominal cysts detected at prenatal ultrasound screening.

This report describes the ultrasonographic findings in 2 fetuses with intra-abdominal tumours. Both were detected in the 32nd week of gestation and could be visualized throughout the pregnancy. Postnatally, the findings were verified at repeated examinations of the infants, and successful operations undertaken at 4 and 8 months of age, respectively. The tumours represented cysts, probably derived from bleeding in diffuse haemangiomas.

Bone mineral content in preterm infants at age 4 to 16.

Using photon absorptiometry the forearm bone mineral content (BMC) was determined in 75 children aged 4 to 16, who all had a low birth weight. Forty-five of them were born preterm AGA (27 boys, 18 girls, mean weight 1 580 g; range 920-2 060 g) and 30 preterm SGA (17 boys, 13 girls, mean weight 1510; range 940-2130 g). The results were compared with a control group of children of the same age, and analyses of covariance with age, height and weight as the covariant factors were performed. The BMC, weight and height did not differ between the children born AGA or SGA. Irrespective of AGA or SGA, the BMC was significantly decreased in boys but the difference was less pronounced and less significant when height and weight were used as covariant factors. Boys who had been born preterm had a less BMC than the control boys for their age but they were also somewhat shorter and lighter than expected with regard to their age.