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Pyuria is common in chronic kidney disease (CKD), which could be due to either urinary tract infection (UTI) or renal parenchymal inflammation. Only little is known regarding the association of pyuria or UTI with renal outcomes. We investigated 3226 patients with stage 3–5 CKD. Pyuria was defined as ≥ 50 WBC per high-power field (hpf) and was correlated to old age, female, diabetes, hypoalbuminemia, lower eGFR, and higher inflammation status. In Cox regression, patients with more than one episode of pyuria in the first year (11.8%) had increased risks for end-stage renal disease (ESRD) [hazard ratio (95% CI): 1.90 (1.58–2.28); p  <  0.001 ], rapid renal function progression [odds ratio (95% CI): 1.49 (1.13–1.95); p  =  0.001 ], and all-cause mortality [hazard ratio: 1.63 (1.29–2.05); p  <  0.001 ], compared to those without pyuria. In a subgroup analysis, the risk of pyuria for ESRD was modified by CKD stages. We investigated the effects of UTI (urinary symptoms and treated by antibiotics) and pyuria without UTI (urine WBC < 50 to ≥ 10/hpf without any episodes of ≥ 50 WBC/hpf or UTI), while both groups were associated with clinical outcomes. In conclusion, CKD stage 3–5 patients with frequent pyuria or UTI episodes have increased risks of renal outcomes.

PurposeLower urinary tract symptoms (LUTS) may be associated with chronic urinary tract infection (UTI) undetected by routine diagnostic tests. Antimicrobial therapy might confer benefit for these patients.Materials and methodsOver 10 years, we treated patients with chronic LUTS. Pyuria was adopted as the principal biomarker of infection. Urinary leucocyte counts were recorded from microscopy of fresh midstream urine (MSU) samples. Antibiotics were prescribed and the prescription adjusted to achieve a measurable clinical response and a reduction in pyuria.ResultsWe treated 624 women [mean age = 53.4 years; standard deviation (SD) = 18] with chronic LUTS and pyuria. Mean duration of symptoms prior to presentation was 6.5 years. Only 16% of MSU cultures submitted were positive (≥105 cfu ml-1). Mean treatment length was 383 days [SD = 347; 95% confidence interval (CI) = 337–428]. Treatment was associated with a reduction in total LUTS (F = 98; p = 0.0001), 24-h frequency (F = 75; p = 0.0001), urinary urgency (F = 90; p = 0.0001), lower urinary tract pain (F = 108; p = 0.0001), voiding symptoms (F = 10; p = 0.002), and pyuria (F = 15.4; p = 0.0001). Full-dose first-generation antibiotics for UTI, such as cefalexin, nitrofurantoin, or trimethoprim, were combined with methenamine hippurate. We recorded 475 adverse events (AEs) during 273,762 treatment days. There was only one serious adverse event (SAE). We observed no increase in the proportion of resistant bacterial isolates.ConclusionThis large case series demonstrates that patients with chronic LUTS and pyuria experience symptom regression and a reduction in urinary tract inflammation associated with antimicrobial therapy. Disease regression was achieved with a low frequency of AEs. These results provide preliminary data to inform a future randomized controlled trial (RCT).

Background Adenosine-5′-triphosphate (ATP) is a neurotransmitter and inflammatory cytokine implicated in the pathophysiology of lower urinary tract disease. ATP additionally reflects microbial biomass thus has potential as a surrogate marker of urinary tract infection (UTI). The optimum clinical sampling method for ATP urinalysis has not been established. We tested the potential of urinary ATP in the assessment of lower urinary tract symptoms, infection and inflammation, and validated sampling methods for clinical practice. Methods A prospective, blinded, cross-sectional observational study of adult patients presenting with lower urinary tract symptoms (LUTS) and asymptomatic controls, was conducted between October 2009 and October 2012. Urinary ATP was assayed by a luciferin-luciferase method, pyuria counted by microscopy of fresh unspun urine and symptoms assessed using validated questionnaires. The sample collection, storage and processing methods were also validated. Results 75 controls and 340 patients with LUTS were grouped as without pyuria (n = 100), pyuria 1-9 wbc μl -1 (n = 120) and pyuria ≥10 wbc μl -1 (n = 120). Urinary ATP was higher in association with female gender, voiding symptoms, pyuria greater than 10 wbc μl -1 and negative MSU culture. ROC curve analysis showed no evidence of diagnostic test potential. The urinary ATP signal decayed with storage at 23°C but was prevented by immediate freezing at ≤ -20°C, without boric acid preservative and without the need to centrifuge urine prior to freezing. Conclusions Urinary ATP may have a role as a research tool but is unconvincing as a surrogate, clinical diagnostic marker.

Background Upper urinary tract infection (UTI) or pyelonephritis may increase the pathogenesis rate and risk of severe complications in children due to kidney atrophy. Objective A set of clinical symptoms, laboratory markers, and ultrasound findings were assessed to achieve the early diagnosis and prognosis of pyelonephritis in hospitalized pediatrics. Methods A cross-sectional study with 104 Iranian children (95 girls and 9 boys) aged 1 month to 12 years with acute pyelonephritis during 2012–2018 was conducted. The ultrasound examination of kidneys and urinary tract during hospitalization, the incidence of clinical symptoms, and laboratory markers in blood and urine were monitored to identify the best predictive factors of early diagnosis of this bacterial infection. Results Three-fourth of the patients had one of the four clinical symptoms of abdominal pain, constipation, dysuria, and vomiting, while others were asymptomatic. A much frequency of pyuria (88.46%), Escherichia coli in urine (92.31%), leukocytosis (81.73%), and high ESR (> 10 mm/h, 92.30%) and CRP (> 10 mg/L, 82.82%) was observed. The kidney and urinary tract ultrasonography only in 32.7% of children revealed findings in favor of pyelonephritis (cystitis, ureteral stones, and hydronephrosis). Conclusion There was a high frequency of clinical signs and laboratory markers associated with pyelonephritis. Ultrasound alone was not an efficient tool to track febrile UTI as most patients presented normal sonography.

New onset erythema and oedema over the previously healed BCG vaccine scar site on the child’s left upper arm during the course of the febrile illness, also termed BCG-itis Results of initial investigations are shown in table 1.Table 1 Results of initial investigations Result Normal range White cell count 15×109/L 5.00-15.00×109/L Absolute neutrophil count 8×109/L 1.50-8.00×109/L Platelets 402×109/L 150-450×109/L C reactive protein 76 mg/L 0-10 mg/L Erythrocyte sedimentation rate 97 mm/h 3-9 mm/h Urinalysis was normal. BCG-itis, raised inflammatory markers, leucocytosis, thrombocytosis, hypoalbuminaemia, anaemia for age, elevated transferase level, and/or pyuria.123 T cell mediated inflammation around a healed BCG inoculation site causes BCG-itis; it is different to BCG vaccination related local reactions, which usually heal after 4-6 weeks.4 As BCG-itis occurs early in the course of Kawasaki disease, it is a useful sign for the early diagnosis of patients with IKD.56 Results from a retrospective case study and a data analysis suggest that BCG-itis is present in 50-70% of classic Kawasaki disease cases and up to 85% of IKD cases,56 and another retrospective case study in 2019 found that, as a sign of Kawasaki disease in infants, BCG-itis had a positive predictive value of 90.8%.7 Prompt treatment with intravenous immunoglobulin (IVIG) reduces the risk of coronary complications.1 Learning point Consider Kawasaki disease in children with high fever and BCG-itis when there is no obvious source of infection, especially if they are from countries where BCG vaccination is part of the immunisation schedule, Patient outcome With IVIG the patient’s fever lysed and her inflammatory markers markedly improved. Diagnosis, treatment, and long-term management of Kawasaki disease: a scientific statement for health professionals from the American Heart Association.

The objective of this study was to assess isolated pyuria in an unselected systemic lupus erythematosus sample, and to determine factors potentially associated with this manifestation. We studied patients followed in our lupus clinic, defining isolated pyuria as more than 10 white blood cells per high power field in the absence of hematuria, proteinuria, casts, or bacteriuria. We assessed the effects of various demographic and clinical factors on the occurrence of isolated pyuria, using univariate logistic regression analyses. We also performed multivariate models which included sex, age, race/ethnicity, systemic lupus erythematosus duration, non-renal systemic lupus erythematosus disease activity, systemic lupus erythematosus damage, number of non-renal and renal American College of Rheumatology criteria ever present, pre-existing hypertension, and current drug exposures. Of 264 subjects, 66 were excluded (43 had bacteriuria or a contaminated urine culture and 23 had no concomitant urine culture); 27 of the remaining 198 (13.6%) had isolated pyuria. Sixteen of 27 patients with sterile pyuria had previous American College of Rheumatology criteria for renal involvement (hematuria, casts, and/or proteinuria) compared to 62/171 patients without sterile pyuria (unadjusted odds ratio = 2.55; 95% confidence interval = 1.11—5.85). Our univariate analyses also suggested a trend towards higher non-renal disease activity in patients with isolated pyuria. Independent associations were not evident in adjusted analyses. Isolated pyuria was observed in a significant number of our systemic lupus erythematosus sample. Although the differential diagnosis for isolated pyuria is broad, this manifestation may be correlated with lupus activity even in the absence of hematuria or proteinuria. Lupus (2010) 19, 793—796.

Kawasaki disease is an acute febrile multisystem vasculitis. The term Incomplete Kawasaki disease is used in the presence of a minimum of two diagnostic criteria of clinical Kawasaki syndrome accompanied by at least 5 days of fever, the absence of any other reasons characterising the disease, and the presence of severe systemic inflammation findings. Gastrointestinal symptoms, notably diarrhoea, abdominal pain, and vomiting, frequently occur, and elevated serum aminotransferases, gallbladder hydrops, and rarely other forms of gastrointestinal involvement such as ischaemic colitis, intussusception, hepatic necrosis, splenic infarct, intestinal pseudo-obstruction, colitis, and colon oedema are also reported. In this paper, we present an incomplete and atypical Kawasaki case that explicitly shows gastrointestinal involvement. Progressive bowel oedema was detected in the patient presenting with severe abdominal pain and distension. We determined an aneurysm in the right coronary artery and diffuse dilatation in the left main coronary artery despite administration of early intravenous immunoglobulin. In addition to the cardiac problem, hypoalbuminaemia, electrolyte imbalance, sterile pyuria, hepatosplenomegaly, and hydrops of the gallbladder were observed in the case. All findings, including progressive bowel oedema accompanying abdominal distension, improved markedly after the second dose of intravenous immunoglobulin.

Correspondence to Dr Aasems Jacob, aasemsj@gmail.com Description A Caucasian woman aged 65 years with a history of chronic alcoholism presented to the hospital with confusion. SSA is responsible for patient care, initial planning, reporting, acquisition of clinical history and review of literature. IV is responsible for patient care, planning and conception of the case report, and acquisition of images. DB is responsible for patient care, supervision of the planning and preparation of manuscript, reviewing the report and editing.

Background. Kawasaki disease (KD) is an acute systemic vasculitis with unknown etiology. The diagnosis of KD depends on clinical manifestations. The prevalence of coronary artery abnormality (CAA) is 11.0% and results in cardiac sequelae, such as myocardial infarction or coronary aneurysm, which are the most serious complications in KD. Methods. We divided KD's children into different age groups: ≤6 months old, 7 months to 1 year old, and >1 year old, respectively. Different parameters were compared in each group. Results. Infants ≤6 months old are less likely to fulfill KD's major diagnostic criteria within 10 days, are prone to develop incomplete KD with the lowest cholesterol level, and have the greatest chance to have CAA and the laboratory features associated with CAA, such as the longest time needed to confirm CA diagnosis, lower hemoglobin level, lower albumin level, and higher platelet count. Infants <1 year old develop higher percentage of leukocytosis and sterile pyuria. But this group has fewer patients with neck lymphadenopathy.