PAEDIATRICS 1

A 5-year-old female child is brought to the ER for fever, chills and abdominal pain. Her parents report that she has been complaining of burning micturition and abdominal pain for the last 2 days. On examination, her vitals are; T: 102 F (38.9C); RR: 20/min; PR: 130/min and BP: 90/60 mm of Hg. Physical examination reveals costovertebral angle tenderness. Urine analysis shows pyuria, significant bacteriuria, WBC casts and is positive for nitrites and esterase. What is the most likely cause of this condition in children?

A. Hydronephrosis
B. Wilm’s tumor
C. Vesicoureteral reflux
D. Ureteral duplication
E. Renal stones

Explanation:
This patient has clinical presentation suggestive of acute pyelonephritis. Vesicoureteral reflux is the most likely cause of acute UTI in this age group. It is more commonly seen in girls.

Vesicoureteral reflux is the retrograde flow of urine from the bladder to the ureter and renal pelvis. Normally, the ureter is attached to the bladder in an oblique fashion, leading to a flap-valve mechanism that prevents reflux, however reflux occurs when the submucosal portion of ureter between the mucosa and detrusor muscle is short or absent. Vesicoureteral reflux is generally congenital and seen in approximately 1% of children.

Reflux is a risk factor for UTI as it facilitates the transport of bacteria from bladder to the upper urinary tract. Reflux is present in 35-40 % of children with UTI and is the most common cause of UTI in this age group. Diagnosis is made with voiding cystourethrogram (VCUG) followed by renal imaging.

Option B: Wilm’s tumor is generally seen in children but is not a common cause of acute UTI.

Option D: Ureteral duplication can lead to vesicoureteral reflux and acute UTI, but most of the vesicoureteral reflux are congenital, run in the families and is due to the anomalous intravesical portion of ureter.

Option A and E: Renal stones and hydronephrosis are not common in this age group.