Pedi gu review fungal and parasitic infections
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Pedi gu review fungal and parasitic infections Pedi gu review fungal and parasitic infections Presentation Transcript

  • Fungal, parasitic, and other inflammatory diseases of the GU tract Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined from The Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007 (not for reproduction, distribution, or sale without consent)
  • Fungal Infections
    • Candidiasis
      • Systemic candidiasis will develop in as many as 4% of preterm neonates weighing 1500 g and 10% weighing 1000g
      • Leading bloodstream isolate from children hospitalized with opportunistic infections
      • Impaired host resistance
  • Fungal Infections
    • Candidiasis
      • IV catheters
      • Long term Abx
      • Steroids
      • Immunosuppressive agents
      • Cytotoxic drug therapy
      • Burns
      • Open surgical wounds
      • ICU stay
      • Surgery on the GI tract
  • Fungal Infections
    • Candiduria
      • Colony counts of greater than 10,000 Candida per 1 ml signify infection
      • Anuria can result from bilateral pelvic fungal balls
      • Should clear after stopping antibiotics
        • May require local skin care for skin irritation
      • Infections limited to bladder may be treated with alkalinization or intermittent ampho B
      • Upper collecting system infection may require treatment with oral 5-flucytosine or NT irrigations with amph
        • Not used with azotemia or bone marrow depression
        • Surgical removal or forced diuresis for fungal balls
    • Systemic candidiasis
        • IV ampho +/- 5-FC (follow Cr for nephrotoxicity)
        • Fluconazole has also been used
  • Fungal Infections
    • Aspergillosis
      • 2nd most common fungal infection
      • Present in soil
      • Acquired via inhalation and then disseminated thru blood
      • Microscopic hematuria and pyuria
      • Urine cultures often inconclusive
      • IV Amphotericin B/irrigations
  • Fungal Infections
    • Coccidioidomycosis
      • Dimorphic fungus
      • GU disease occurs with disseminated disease
      • Small miliary granulomas within kidney
      • Infundibular stenoses/blunted calyces
      • Ampho B, Fluconazole, Ketoconazole
  • Parasitic Infections
    • Schistosomiasis
      • Endemic in Egypt and has spread
      • Humans infected thru contact in water and then crecariae migrate to portal circulation to reach sexual maturity
      • Adult worms migrate to perivesical and periureteral plexi
      • Upon fertilization, eggs deposited in venules which reach urinary lumen
  • Parasitic Infections
    • Schistosomiasis
      • Acute episode 3-9 wks after infection with terminal hematuria and dysuria (anemia)
      • Urinary tract pathology can decrease with age
      • Eosinophilic infiltrate within bladder wall and collagen infiltration
      • Involvement of trigone and bladder neck pronounced
      • Vesical calculi
      • VUR in up to 50%
      • Diagnose via presence of terminal-spined eggs in urine
  • Parasitic Infections
    • Schistosomiasis
      • Peripheral blood with eosinophilia
      • “ Egg shell” bladder on plain film
      • Hydro secondary to ureteral stricture
      • Drug of choice is praziquantel
      • Fibrosis and contracture may require autoaugment or replacement
  • Parasitic Infections
    • Echinococcosis
      • Most prevalent human cestode (hydatid cyst)
      • Dog tapework Echinococcus granulosus
        • Lives in intestine of dogs
      • In humans affects primarily liver
      • 3% of infections involve kidneys
      • Growth rate of 1 cm/yr
      • Present as painful flank mass
      • Sonography most useful
      • 1/3 of children will have eosinophilia
      • Ab Immunoelectrophoresis is most specific
  • Parasitic Infections
    • Echinococcosis
      • Treat with albendazole
      • Positive response in pediatrics 40-60%
        • Follow with ultrasound
      • Percutaneous drainage has become more succesful
        • Anaphylactic reaction still a possibility
  • Parasitic Infections
    • Enterobiasis
      • Pinworm carried on fingernails, clothing, bedding
      • Live in large intestine
      • Perianal irritation
      • 22% of girls with UTIs had pinworm infestation vs 5% of control
      • Diagnosis with adhesive tape to perianal region early in the morning
      • Treat with pyrantel pamoate or mebendazole
  • Other Inflammatory
    • Chlamydia
      • Obligate intracellular bacteria
      • Perinatally transmitted or STD
        • 25% of pregnant women cervical infections
        • Conjunctivitis and pneumonia
        • May persist for 3 years without symptoms
      • Boys clear mucoid urethral discharge with or without urinary symptoms
      • Diagnosis with culture
      • Antibiotics: Sulfonamides, E-mycin, tetracyclines 10-14 days
  • Other Inflammatory
    • Viral Cystitis
      • Severe hemorrhagic viral cystitis seen in pediatric patients undergoing BMT
      • Usually adenovirus type 11, 21; Influenza A, CMV
      • Viral shedding 4 days to 2 weeks
      • Herpes zoster may also cause symptoms
      • Adenovirus diagnosed with immunofluorescence of antigen and u/s may show thickened bladder (resolves 2-3 weeks)
      • Polyoma BK virus:BMT patients
        • Epithelial cells within the urine containing intranuclear inclusion bodies
      • Many immunocompromised patients do not respond to traditional therapies for hemorrhagic cystiis and may progress to ARF
  • Other Inflammatory
    • Viral Cystitis
      • Use of ribavirin for acute adenovirus hemorrhagic cystitis
      • Instillation of PG E1 in bladder for up to 7 days
      • Hyperbaric oxygen
  • Other Inflammatory
    • Eosinophilic cystitis
      • Irritative voiding symptoms
      • Palpable suprapubic mass
      • Eosoniphilia usually not found
      • Focal thickening of the bladder
      • Definitive diagnosis by cysto/bx
      • Etiology unknown ?IgE mediated to allergen
        • Tx with removing allergen (usually not identified)
          • Cases usually resolve within 12 weeks
          • Recurrence still possible
  • Other Inflammatory
    • Malacoplakia
      • Benign granulomatous condition
      • Defective digestion of phagocytosed bacteria
      • Intracyctoplasic inclusions
      • Can affect multiple organs (most common kidney in pediatrics)
      • Occurs in setting of recurrent UTIs
      • Nephromegaly without abscess
      • Diagnosis with bx
      • Bilateral renal malacoplakia was considered fatal but can be tx with antimicrobial and G-CSF
  • Other Inflammatory
    • Epididymitis
      • Inflammatory reaction
      • Scrotal pain/edema
      • Only 24% of patients had >10 WBC per hpf on UA and urine cultures only positive 10%
      • For culture proven bacterial epididymitis:
        • At minimum RUS and VCUG should be performed
      • Dysfunctional voiding 25%
        • Uroflow, patch EMG, PVR for boys over age of 5
  • Other Inflammatory
    • Vulvovaginitis
      • Most common prepubertal complaint
      • Ages 2-7 yrs with discharge, discomfort, pruritus, urinary symptoms
      • Vulva of young female is unprotected and children also have poor hygeine; also potential for foreign body and sexual abuse
      • History should entail chemical exposures
      • Formal vaginoscopy may be required
      • Treatment or behavioral modification
  • Other Inflammatory
    • Idiopathic scrotal and penile edema
      • Up to 20% of acute scrotal inflammation
      • Sudden 1 day onset of unilateral/bilateral scrotal erythema
      • Occasional eosinophilia
      • May be related to angioedema and is self limitting
  • Other Inflammatory
    • IC
      • Day and night frequency, abdominal pain, decreased bladder capacity, negative UA/culture
      • Of 16 individuals over a 12 year period, 70% girls and 30% boys
      • Glomerulations and terminal hematuria with hydrodistension
      • Treatment poor results