Sally, a usually healthy Caucasian 3-year-old with blond hair, presented to the local emergency department (ED) with sudden onset of fever and chills. She was whimpering and clinging to her mother. During history-taking, Sally’s mother reported that the girl had exhibited no previous signs of illness; she had been running and playing normally the day before. Her temperature in the ED, however, was 103.6°F. Mucous membranes were slightly dry. Neurologic assessment was normal. Heart and respiration rates were slightly elevated.

Sally was born following a normal, full-term pregnancy. Birth weight was 8 lb 6 oz. Apgar scores were normal. Her only significant illness had been a bout with respiratory syncytial virus when she was 1 month old. She was current on her vaccinations. Although potty-trained, she still had frequent wetting accidents.

The toddler’s WBC count was 17,000/µL with 82% polymorphonuclear cells. Pulse oxygenation measured 98% on room air. A straight catheter urine sample showed WBCs too numerous to count and came back positive for leukocyte esterase and nitrites.

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1. Diagnosis

Sally was diagnosed with acute pyelonephritis. She was given a loading dose of IV ceftriaxone (Rocephin), rehydrated with normal saline, and sent home with oral antibiotic coverage and acetaminophen for fever. Her recovery was uneventful, but she continued to have wetting accidents daily.

Fewer than six months after her visit to the ED, Sally had a recurrence of pyelonephritis. After an uneventful treatment and recovery, she was referred to a urologist for evaluation.

A voiding cystourethrogram (VCUG) and an IV pyelogram revealed a classic “spinning top” urethral distortion with a grade IV ureteral dilatation and hydronephrosis on the left side due to severe vesicoureteral reflux (VUR).

2. Discussion and treatment

VUR occurs 10 times more frequently in white children than black and five to six times more often in girls than
boys. Girls who have red hair are especially predisposed to this condition. Individuals with a previous history of UTIs have a higher incidence (40%-50%) of VUR. Approximately 13,000 children are hospitalized each year in the United States requiring treatment of complications of VUR (e.g., pyelonephritis).

Primary causes of VUR are usually congenital, such as malformation of the vesicoureteral junction. Secondary causes include chronic infections of the lower urinary tract, bladder outlet obstructions, and detrusor instability. This instability gives rise to the “spinning top” formation of the distal urethra. The intrinsic neuromuscular coordination of voiding becomes confused, and voiding pressures build up in this portion of the urethra. Hence incomplete emptying, frequent wetting, high postvoid residual volumes, and, eventually, VUR develop.

VCUG is the key test to diagnose VUR and track its resolution. Treatment consists of daily prophylactic antibiotic use, voiding schedules, prevention of constipation, and, often, pharmacologic detrusor stabilization with anticholinergic medication. VUR that is not a result of structural malformations typically resolves as the child grows but must be monitored to prevent worsened hydronephrosis and renal damage.

Sally is now 7 years old and has been free of UTI for almost three years. She takes daily antibiotic prophylaxis and detrusor stabilization medication. Her wetting accidents have stopped. Twice a year, she has a VCUG, but such testing will become unnecessary as she grows.

Ms. Sego is a primary-care nurse practitioner at the Department of Veterans Affairs Medical Center in Kansas City, Mo., and a contributing editor to The Clinical Advisor.

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All electronic documents accessed November 13, 2009.