A 12-year-old boy presented with 1 month of fever, right flank pain, and a 15-day history of swelling in the right flank region. His past medical history included a previous hospitalization 2 years prior for fever and right flank pain where he was diagnosed with right renal calculi. On examination, he appeared wasted and pale with tenderness and a hard, mobile swelling in the right flank region. Differential diagnoses included pyelonephritis, renal tuberculosis, and renal cell carcinoma. Pyelonephritis is the most common diagnosis in infants under 24 months presenting with fever without an obvious focus. It is classified into acute or chronic forms, with xanthogranulomatous pyelonephritis
2. Presenting complain
A 12 year old boy presented in CLF-P2 with
complain of
Fever for 1 month
Pain in the right flank region for 1 month
Swelling in the right flank region for 15 days.
3. History of presenting complain
According to the uncle boy was in his usual health
then developed Fever one month back, low grade
fever, undocumented, intermittent, temperature
increases at night without rigors, chills and
sweating, relieved with paracetamol. Associated
with the pain in the right flank region for 1 month.
Continues dull pain, radiating to the back ,
aggravate with walking and relieved with ibrufen,
the intensity of pain is increasing day by day.
From last 15 days patient developed swelling in
the right flank region, hard tender swelling and
slowly increasing in size with time. There is no
history of trauma to the right flank.
4. Past medical history
There is previous history of hospital admission
2 years back with complain of fever and pain
in the right flank region and pt diagnosed with
RT renal calculi and was treated
conservatively by urology department and was
advised to visit again after 2 weeks but patient
didn’t comply.
Past drug history
According to the uncle doctor prescribed
antibiotic for 10 days and syp brufen for pain.
And pt have been taking ibrufen on and off for
pain since then.
5. Family history
Grand mother had TB and was on ATT and
died during therapy 6 months back, mother
also has TB and was taking ATT but then she
stopped after 3 to 4 months of treatment.
Uncle also has TB but he lives in other city.
HCV: no
HBV: mother is positive
HTN: grand mother
DM-II : grand mother
6. Vaccination history:
Partialy vaccinated card is not available and
BCG mark is absent.
Birth history: unremarkable
Developmental histroy: all mile stones
achieved according to age.
Socioeconomic Status: poor
Father died due to excessive use of alcohol
leads to CLD
Line water without boiling
7. Nutritional history
DMF: for 2 years
Complementry feed started after 6 to7 months
of age.
breakfast: 2 slices of bread with cup of tea
Sometimes with one egg and half paratha.
Lunch: ½ chapati with salan of daal or
vegetable.
Dinner: one bowl of rice with glass of milk.
They usually have meat twice a week
Total calories intake per day: 575
8. On examination
G/ look: patient is wasted , pallor, no edema , jaundice
, cyanosis and clubbing
MUAC= 11.5cm
Lt= 128.5cm
CNS: conscious and well oriented
CVS: S1+ S2 audible
Chest: b/l normal and equal air entry with no added
sounds
Abdomen soft and tender in RHC and RT flank region.
There is swelling in the right flank region
Inspection of swelling: the overlying skin is red & no
visible pulsation and scar makrs
Palpation: hot & tender to touch , mobile, hard
consistency, smooth surface and measuring size
26. Pyelonephritis
Inflammation of renal parenchyma.
Pyelonephritis is the most common serious
bacterial infection in infants younger than
24months of age who have fever without an
obvious focus.
Pyelonephritis is one of the basic form of UTIs.
Classified into acute and chronic pyelonephritis .
Xanthogranulomatous pyelonephritis is a rare and
aggressive variant of chronic pyelonephritis. It
usually occurs due to chronic nephrolithiasis and
infection. The diagnosis is often confused with
renal cell carcinoma. It is characterised by
granulomatous inflammation with giant cells and
foamy histiocytes.
28. Urinary tract infection
UTIs often are separated into infections of the
lower urinary tract that involve the bladder and
urethra and those of the upper tract that
involve the kidneys, renal pelvis, and ureters.
Infections of the upper tract are designated
pyelonephritis.
Age and sex are the most important factors.
UTI is more common in preschool-age
children.
During first year of life male:female ratio is
2.8:5.4 and beyond 1-2yrs there female
preponderance having ratio of male:female
29. Classification of UTI and clinical
manifestations
UTI is classified into two basic forms
1/ Pylonephritis
2/ cystitis
30. Etiology
E-coli 54% to 67% (80% of cases of
pyelonephritis)
Klebsiella
Proteus
Enterococus
Pseudomonas
Group B stretococcus
Less common staph aureus, salmonella and
candida sp.
32. Clinical features of
pyelonephritis
Abdominal pain or flank pain
Fever
Malaise
Nausea
Vomiting
Occasional diarrhea
Fever and irritability are the most common
presenting findings in infants who have
pyelonephritis.
33. Diagnosis
Based on symptoms and urine analysis
Urine DR and CS
Urine sample (toilet trained and untoilet
trained)
CBC (leukocytosis and neutrophilia suggest
acute renal infection)
Increased ESR
Increased CRP
Ultrasound
CT-scan
34.
35.
36.
37. Treatment
Lower UTI(cystitis)
Trimethoprim-sulfamethoxazole 6-12mg/kg/day
divided into 2 doses (e-coli).
Nitrofurantoin 5-7mg/kg/day divided into 3-4
doses.
Amoxicillin 50mg/kg/day divided into 2 doses.
Upper UTI (pyelonephritis)
7 to14days therapy
Ceftriaxone 50mg/kg/day or cefotaxime 100-
150mg/kg/day divided 3-4 doses and pt is able to
take oral then shift to cefixime, cefixime is as
effective as ceftriaxone.