Prolonged fever and pyuria: a urinary tract infection presentation of incomplete Kawasaki disease

We report two patients with incomplete Kawasaki disease that presented as apparent urinary tract infection. Persistent fever and pyuria were the initial presentation without concomitant signs suggestive of Kawasaki disease; thus the patients were treated as urinary tract infection. Fever persisted despite antibiotic treatment. Diagnostic criteria of Kawasaki disease were not fulfilled for these two patients, yet aneurysmal dilatation of the coronary artery was noted 10 and 18 d, respectively, after the onset of fever. The diagnosis of incomplete Kawasaki disease was assigned when the coronary artery abnormality was detected. Fever subsided within 24 h of administration of intravenous immunoglobulin.

CONCLUSION

This report highlights the potentially misleading presentation of fever and pyuria as the sole initial manifestation of incomplete Kawasaki disease. Echocardiography is indicated to detect coronary artery abnormality when fever persists in such patients after adequate antibiotic treatment and thorough urological evaluation.

Severe pulmonary hemorrhage as the initial manifestation in systemic lupus erythematosus with active nephritis

Pulmonary hemorrhage (PH) is an uncommon clinical manifestation of patients with systemic lupus erythematosus (SLE). In this report, we describe a 14-year-old male with PH as the sole clinical manifestation of his SLE. Kidney biopsy was performed and the report revealed lupus nephritis class IVb. He demonstrated a rapid clinical response to the therapy of intravenous pulse methylprednisolone. Awareness of the possibility of PH as a sole clinical presentation of SLE may aid in the diagnosis and early aggressive management of this condition.

Treatment guideline of enuresis in Taiwan

The treatment guideline of enuresis suggested by the study group of enuresis in Taiwan is reported. Medical consultation and treatment of enuresis are recommended at the age of 5 and 6 years respectively. Evaluation of the enuretic children includes history taking, physical examination and laboratory investigations. A checklist is provided for quick evaluation in busy clinics. Urinalysis, urine specific gravity and office ultrasonography are essential tests. An algorithm of treatment of monosymptomatic enuresis is constructed. The two main options of treatment are behavioral modification with alarm system and pharmacotherapy with desmopressin or imipramine. Imipramine is recommended as one of the treatment options because of its relative safety in Taiwan. However the potential toxicity and mortality of imipramine is highlighted and warned. The responses to treatment are evaluated after a period of treatment for 1 to 3 months. Further evaluation and individualized treatment is suggested for poor responders.

99Tcm-dimercaptosuccinic acid renal scintigraphy for detection of renal cortical defects in acute pyelonephritis: posterior 180 degrees SPECT versus planar image and 360 degrees SPECT

To evaluate the usefulness of the posterior 180 degrees acquisition technique for renal defects in acute pyelonephritis (APN), a prospective study was conducted using planar imaging, 360 degrees and posterior 180 degrees renal single photon emission computed tomography (SPECT) with 99Tcm-dimercaptosuccinic acid. Sixty subjects with the suspicion of APN were included. The kidneys were divided into three zones: each was graded as positive, equivocal or negative for renal defects. To evaluate inter-observer variation, each study was read in a double-blind fashion by two nuclear physicians. Renal defects were found in 24 patients (31 kidneys and 47 zones) with posterior 180 degrees SPECT, 23 patients (29 kidneys and 44 zones) with 360 degrees SPECT (McNemar's test, P = 0.375 for zones) and 15 patients (16 kidneys and 24 zones) with planar image (P = 0.001 for zones, vs 180 degrees and 360 degrees SPECT). The proportion of positive agreement for posterior 180 degrees and 360 degrees SPECT between readers for the presence of renal defects was 0.81 and 0.62, respectively, whereas the proportion of negative agreement was 0.92 and 0.87, respectively. Both posterior 180 degrees and 360 degrees SPECTs significantly detected more renal defects than planar imaging. The detectability of renal defects in APN by posterior 180 degrees renal SPECT was equal to 360 degrees SPECT but inter-observer agreement was better.

Left multicystic dysplastic kidney with contralateral ectopic kidney and ureterovesicle junction obstruction

Multicystic dysplastic kidney (MCDK) represents the most common cause of abdominal mass in the neonatal period. It is usually combined with contralateral genitourinary tract anomaly. Because the multicystic dysplastic kidney is usually dysfunctional, it is important to evaluate and monitor the remaining preserved function of the contralateral kidney regularly. The presence of severe obstructive lesion over contralateral kidney is often life-threatening. Prompt treatment should therefore be given as early as possible to preserve the remaining renal function. We here report one rare case of left MCDK with contralateral ectopic kidney and ureterovesicle junction (UVJ) obstruction. As the best as we know, this report is the first case report of MCDK with contralateral ectopic kidney and UVJ obstruction.

Cerebral vasculitis in Henoch-Schönlein purpura: a case report with sequential magnetic resonance imaging changes and treated with plasmapheresis alone

Neurological complications are rare during the course of Henoch-Schönlein purpura (HSP). We report a 7-year-old girl with HSP who presented with seizures, loss of vision and disturbance of consciousness. Magnetic resonance imaging (MRI) showed high signal intensity in the gray and white matter over the left parietal and both occipital lobes, compatible with MRI findings of cerebral vasculitis. The eye fundi revealed multiple branches of retinal artery occlusion. Intravenous pulse methylprednisolone (MTP) followed by oral steroid therapy was initially administered for HSP nephritis. Cerebral vasculitis developed 10 days post-MTP treatment, with progressive worsening of consciousness. Oral steroid was discontinued and plasmapheresis was performed alone. Her level of consciousness dramatically improved after plasmapheresis. The brain MRI and eye fundi findings were consistent with her clinical improvement. To the best of our knowledge, this is the first description of MRI abnormalities and multiple retinal artery branch occlusion of cerebral vasculitis in a patient with HSP that was successfully treated by plasmapheresis alone. In conclusion, we propose that plasmapheresis may be used as a first-line therapy or rescue therapy for cerebral vasculitis in HSP.

Posterior 180 degrees 99mTc-dimercaptosuccinic acid renal SPECT

As a result of a high percentage of hypoactive upper poles of kidneys in traditional 99mTc-dimercaptosuccinic acid (DMSA) SPECT, a prospective study was conducted using 180 degrees acquisition technique compared with 360 degrees to minimize tissue attenuation.

METHODS

Anterior 180 degrees, posterior 180 degrees and 360 degrees renal SPECT images were obtained simultaneously using a dual-head camera. Forty-one subjects without renal disease and 16 subjects with 21 cortical defects were included in this study. The total counts of the raw data in the anterior 180 degrees, posterior 180 degrees and full 360 degrees were calculated. Small regions of interest were drawn over the cortex of the kidney on coronal and reoriented sagittal slices. Quantitative evaluation of regional activity was performed on the same frames in all three acquisition methods.

RESULTS

Comparison of the total renal counts between the anterior and posterior 180 degrees data showed reduced counts in the anterior 180 degrees data collection (P < 0.01). Visual evaluation of the reconstructed images from anterior 180 degrees, posterior 180 degrees and full 360 degrees data collection showed the best image uniformity in the posterior 180 degrees image. The upper/lower pole ratio in the posterior 180 degrees renal SPECT images increased significantly in comparison to full 360 degrees renal SPECT images (P < 0.01) and anterior 180 degrees SPECT images (P < 0.01). The renal defects were more clearly visualized in the posterior 180 degrees renal SPECT images than the full 360 degrees renal SPECT images. The defect/normal cortex ratios in the posterior 180 degrees renal SPECT images were much lower than those from the full 360 degrees SPECT images (P < 0.01) and those from the anterior 180 degrees SPECT images (P < 0.01).

CONCLUSION

The posterior 180 degrees acquisition technique can avoid the problem of hypoactive upper pole and can be less time consuming in 99mTc-DMSA SPECT images. It also provides superior lesion contrast in the clinical evaluation of patients with renal scarring.

Clinical aspects of the hemolytic uremic syndrome

Hemolytic uremic syndrome (HUS) can be clinically classified into two types: typical cases with a diarrheal prodrome of association with E. coli O157, and atypical cases without antecedent diarrhea. However, HUS is not common in Taiwan. To evaluate the clinical course, complications and outcome of HUS in children, and to identify the risk factors for mortality, retrospectively, seven cases of HUS in our hospital in the past 6 years were studied. Six of them were boys, and one was a girl. Their ages ranged from 0.67 to 3 years. None of them were preceded by diarrheal prodrome. Acute renal failure, hypertension and liver involvement were noted in all cases. Stroke and seizure developed in three of the cases with sequelae. Two cases progressed into end-stage renal disease (ESRD). One case developed acute respiratory distress syndrome (ARDS). Two cases (28.5%) expired. ESRD especially associated with ARDS was highly related to mortality.

Intravenous pretreatment of hypertonic saline can prevent systemic hypotension induced by spinal anesthesia

BACKGROUND

Hypertonic saline improves organ perfusion and patient survival during hemorrhagic shock because it expands plasma volume and increases tissue oxygenation. Its beneficial results have been reported in patients suffering from hypotension during spinal anesthesia. The purpose of this study was to compare the influence between prehydration with 3% hypertonic saline and with isotonic lactated Ringer's solution on the hemodynamic changes and serum electrolyte concentrations in patients undergoing spinal anesthesia.

METHODS

Sixty ASA class I patients scheduled for herniorrhapy under spinal anesthesia were assigned randomly into two groups. Group 1 = patients were prehydrated with isotonic lactated Ringer's solution at 7 mg/kg (n = 30); Group 2 = patients were given prehydration with 3% hypertonic saline at 7 ml/kg (n = 30). Following prehydration, arterial blood pressure and heart rate were recorded and serum electrolyte concentrations were measured.

RESULTS

The incidence of hypotension was 17/30 (57%) in the isotonic lactated Ringer's solution group as against 7/30 (23%) in the hypertonic saline group (p < 0.05). There was no significant difference between two groups in relation to the level of anesthesia or maximal heart rate, and electrolyte imbalance did not occur in either group.

CONCLUSIONS

Prior to spinal anesthesia, hydration with small amount of hypertonic saline is effective to minimize hypotension associated with spinal anesthesia. If so administered it would not increase bodily sodium load and unlike isotonic crystalloid solution it dose not cause accumulation of water in the body on equipollent basis.

Continuous ambulatory peritoneal dialysis for children with end stage renal disease

From June 1986 to October 1989, ten children suffering from end stage renal disease (ESRD) were treated with continuous ambulatory peritoneal dialysis (CAPD). Their ages ranged from 4 to 16 years; 3 were boys and 7 were girls. IgM mesangial nephropathy (IgMN) (three cases) were the most common causes of renal failure in the patients. All patients were trained in the hospital. After CAPD treatment, serum BUN and creatinine dropped significantly. Serum levels of potassium, phosphorus, and alkaline phosphatase dropped and serum sodium and calcium rose significantly after treatment. Improvement of anemic state and control of hypertension were also noted. Hypercholesterolemia and hypertriglyceridemia developed after CAPD treatment. Despite protein loss through the peritoneal cavity, there was no evidence of protein malnutrition. Total serum protein and albumin increased significantly after treatment. The most common complication was peritonitis. Three of these 10 patients developed an episode of peritonitis, or an incidence of 1 episode per 17.2 patient months. To the present, seven patients are still doing well on CAPD. Three patients have received renal transplantation. The majority of the patients experienced an increased sense of well-being, easier diet and fluid management, freedom for travel and daily activities. Physical development also improved, with body length and body weight gaining steadily. It can be concluded that CAPD is a good modality of long-term therapy for ESRD children.