1. Intern Seminar Renal Abscess in Children VS 邱元佑 R4 周信旭 Speaker 陳如蘋

2. Brief Hx 13y/o female, 165 cm/ 98 kg C.C.: fever and headache for 3 days Impression: r/o meningitis, r/o gastritis fever and headache for 3 days Vomiting noted persistent fever

3. Physical Examination Head: Kernig sign (-), Bruzinski sign (-) conj: not anemic; sclera:not icteric throat: not injected; eardrum: intact Abd: soft and obese, mild tenderness(+) over LUQ, rebounding pain(-), muscle guarding(-), flank pain(-), BS: hyperactive

4. Lab 92/12/07 CBC: WBC 24.3K / Band 23% / Seg65% Chem: CRP 82.8 U/A: WBC 6-8 / RBC 10-12

5. Clinical Course Fever(+), Watery diarrhea ~3/d Stool OB(-) Rotavirus Ag rapid dx(-) Stool culture(-) Renal echo 12/8 Fever(+), watery diarrhea(+) ~1 time/d PE: mild tenderrness over LUQ 12/ 10 U/A: WBC 1-2 RBC 3-4 U/C: E.coli (91,000CFU/ml) Lab: WBC 7.8K Band 27% Seg 40% CRP 91.2 12/11

6. Abdominal CT Pre- ContrastPost- Contrast

7. Abdominal CT Pre- ContrastPost- Contrast

8. Abdominal CT Pre- ContrastPost- Contrast

9. Fever Curve Keflin + GM Unasyn + Amikin

10. Discussion Renal Abscess in Children

11. Introduction Renal abscess is rare in children and diagnosis may be difficult. Incidence rate: 1-10 per 10,000 hospital admissions. Steele et al 1990: renal abscess with peak incidence between 7-9 years

12. Introduction Three pathophysiologic mechanisms: 1. Hematogenous spread 2. Ascending infection 3. Contamination by proximity to an infected area

13. Intrarenal abscess Renal cortical abscess: a primary focus of infection elsewhere in the body S. aureus Renal corticomedullary abscess: ascending infection E. coli

14. 1996-2000: 8/ 473 UTI children Acta Pediatr Tw 2003; 44: 197-201

15. 1996-2000: 8/ 473 UTI children Child Age/Max. T S/S CRP Leukocyte No. Sex ( 0 C) (10 3 /ml) 1 6mo/M40.5Fever 99.3 19.8 2 17mo/F39Abdominal pain, fever 87.4 10.5 3 156mo/F39.3Poor activity, poor appetite, fever 267 34.9 4 23mo/F40Fever, mixed with URI 521.749.7 5 43mo/F41Abdominal pain, vomiting, fever 22911.4 6 60mo/F39.9Abdominal pain, vomiting, fever 349.913.4 7 26mo/F39Poor appetite, vomiting, fever 22.2 21 8 36mo/F40Abdominal pain, poor appetite, 184.1 61 fever *U/C: all E. coli except No. 2 and 7 were sterile

16. Febrile days before admission seems parallel to febrile days after antibiotics treatment

17. Acta Pediatr Tw 2003; 44: 197-201

18. No.U/SCTRenal SPECT - initial Renal SPECT - followed VU reflux 1Bil. APNR ’ t ABN with small abscesses Bil. APNNormalNo 2Bil. APN, R ’ t upper abscess R ’ t multiple abscesses Bil. APNBil renal scar No 3Bil. APNBil. ABN with abscesses Bil. APNR ’ t renal scarNo 4Bil. APNR ’ t multiple abscesses Bil. APNBil renal scarNo 5L ’ t renal abscess L ’ t multiple abscesses Mixed Ch. and Ac. L ’ t PN renal scar L ’ t grade I 6L ’ t APNL ’ t multiple abscesses Bil. APNNA 7Bil. APN, r/o ABN or abscess R ’ t multiple abscesses NANormalR ’ t grade II 8L ’ t APN, r/o ABN or abscess L ’ t multiple abscesses L ’ t APNL ’ t renal scarL ’ t grade III

19. 1990-2000: 6 p’ts / University of Texas Medical Branch Pediatr Surg Int (2003) 19: 35–39

20. Signs and symptoms Pediatr Surg Int (2003) 19: 35–39

21. A renal abscess should be considered In any child present with fever, abd pain, flank pain, costovertebral angle tenderness, + a palpable mass, leukocytosis, elevated ESR In p ’ ts with sonographic evidence of focal bacterial pyelonephritis (25% risk of progression)

22. Risk Factors Anatomic or functional uropathy, esp. VUR Pediatrics 2002; 109:165-6 Recent urologic or abdominal Sx Pediatrics 1994; 93:261-4 Recent concomitant infections Pediatr Infect Dis J 8:167-70

23. Image study for renal abscess - US and CT US and CT greatly facilitate the diagnosis and permit the percutaneous drainage of renal abscess in pediatric age group. Although ultrasound is the best modality for imaging a renal abscess, computed tomography provides better tissue contrast, especially in obese patients.

24. US findings: 5y/o F FUO 12/1012/12

25. DMSA renal SPECT A noninvasive imaging study High sensitivity and specificity to detect renal inflammation (sensitivity of detecting APN ~96%) Less useful to detect anatomic change

26. Treatment High cure rate! Small abscesses (< 3cm) in immunocompetent p ’ ts: IV A/B and/or percutaneous drainage 1. Initial : aminoglycoside and either ampicillin or cephalosporin. 2. 3 rd cephalosporins, broader-spectrum penicillins or intravenous TMP-SMX is equivalent to empiric combination therapy.

27. Treatment Large(> 5cm) and medium(3-5cm) renal abscesses: open Sx Reported kidney loss: 16-25%

28. Table 3. Treatment algorithm Pediatr Surg Int (2003) 19: 35–39

29. Thanks for Your Attention!

30. Pediatrics 2000; 105:E59