Intern Seminar
Renal Abscess in Children
VS 邱元佑
R4 周信旭
Speaker 陳如蘋
Brief Hx
13y/o female, 165 cm/ 98 kg
C.C.: fever and headache for 3 days
fever and
headache
for 3 days
Vomiting
noted
persistent
fever
Impression: r/o meningitis, r/o gastritis
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
Lab 92/12/07
CBC: WBC 24.3K / Band 23% / Seg65%
Chem: CRP 82.8
U/A: WBC 6-8 / RBC 10-12
Clinical Course
Fever(+),
Watery
diarrhea ~3/d
12/8
Stool OB(-)
Rotavirus Ag
rapid dx(-)
Stool culture(-)
Renal echo
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)
12/11
Lab:
WBC 7.8K
Band 27%
Seg 40%
CRP 91.2
Abdominal CT
Pre- Contrast
Post- Contrast
Abdominal CT
Pre- Contrast
Post- Contrast
Abdominal CT
Pre- Contrast
Post- Contrast
12/17
12/16
12/15
12/15
12/14
12/13
Keflin + GM
12/12
12/11
12/11
12/10
41
40
39
38
37
36
35
34
33
12/9
12/8
12/7
12/07.4am
Fever Curve
BT
Unasyn + Amikin
BT
Discussion
Renal Abscess in Children
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
Introduction
Three pathophysiologic mechanisms:
1.Hematogenous spread
2.Ascending infection
3.Contamination by proximity to an
infected area
Intrarenal abscess
Renal cortical abscess:
a primary focus of infection elsewhere
in the body
S. aureus
Renal corticomedullary abscess:
ascending infection
E. coli
1996-2000: 8/ 473 UTI children
Acta Pediatr Tw 2003; 44: 197-201
1996-2000: 8/ 473 UTI children
Child Age/
No.
Sex
Max. T
(0C)
S/S
CRP
Leukocyte
(103/ml)
1
6mo/M
40.5
Fever
99.3
19.8
2
17mo/F
39
Abdominal pain, fever
87.4
10.5
3
156mo/F 39.3
Poor activity, poor appetite, fever
267
34.9
4
23mo/F
40
Fever, mixed with URI
521.7
49.7
5
43mo/F
41
Abdominal pain, vomiting, fever
229
11.4
6
60mo/F
39.9
Abdominal pain, vomiting, fever
349.9
13.4
7
26mo/F
39
Poor appetite, vomiting, fever
22.2
21
8
36mo/F
40
Abdominal pain, poor appetite,
fever
184.1
61
*U/C: all E. coli except No. 2 and 7 were sterile
Febrile days before admission seems parallel to
febrile days after antibiotics treatment
Acta Pediatr Tw 2003; 44: 197-201
No.
U/S
CT
Renal SPECT - Renal
initial
SPECT followed
VU
reflux
1
Bil. APN
R’t ABN with small
abscesses
Bil. APN
Normal
No
2
Bil. APN, R’t
upper abscess
R’t multiple
abscesses
Bil. APN
Bil renal
scar
No
3
Bil. APN
Bil. ABN with
abscesses
Bil. APN
R’t renal scar No
4
Bil. APN
R’t multiple
abscesses
Bil. APN
Bil renal scar
5
L’t renal
abscess
L’t multiple
abscesses
Mixed Ch. and Ac. L’t
L’t
PN
renal scar grade I
6
L’t APN
L’t multiple
abscesses
Bil. APN
NA
NA
7
Bil. APN, r/o
R’t multiple
ABN or abscess abscesses
NA
Normal
R’t
grade
II
8
L’t APN, r/o
L’t APN
L’t renal scar L’t
grade
III
L’t multiple
ABN or abscess abscesses
No
1990-2000: 6 p’ts / University of Texas
Medical Branch
Pediatr Surg Int (2003) 19: 35–39
Signs and symptoms
Pediatr Surg Int (2003) 19: 35–39
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)
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
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.
US findings:
12/10
5y/o F FUO
12/12
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
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. 3rd cephalosporins, broader-spectrum
penicillins or intravenous TMP-SMX is
equivalent to empiric combination therapy.
Treatment
Large(> 5cm) and medium(3-5cm)
renal abscesses: open Sx
Reported kidney loss: 16-25%
Table 3. Treatment algorithm
Pediatr Surg Int (2003) 19: 35–39
Thanks for Your Attention!
Pediatrics 2000; 105:E59
Pediatrics 2000; 105:E59
Pediatrics 2000; 105:E59