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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 2  |  Page : 282-284
Renal abscess in a child with sickle cell anemia


Department of Pediatrics, Mahatma Ghandi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India

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   Abstract 

Renal abscess is rare in children and the usual presenting features include fever, lumbar pain, abdominal pain and occasional flank mass. Renal ultrasonography facilitates an early diagnosis and helps in percutaneous drainage. We herewith report on a child with sickle cell anemia who developed a renal abscess.

How to cite this article:
Taksande AM, Vilhekar K Y. Renal abscess in a child with sickle cell anemia. Saudi J Kidney Dis Transpl 2009;20:282-4

How to cite this URL:
Taksande AM, Vilhekar K Y. Renal abscess in a child with sickle cell anemia. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2014 Oct 23];20:282-4. Available from: http://www.sjkdt.org/text.asp?2009/20/2/282/45580

   Introduction Top


Sickle cell disease is an inherited disorder of hemoglobin synthesis, which affects many individuals worldwide. Vaso-occlusive, aplastic and sequestration crises are common in a sickle cell child but renal complications are very rare. Renal abscess as such, is very rare in children. Fever, lumbar pain, abdominal pain and occasional flank mass are the presenting features of renal abscess. The development of renal abscess can be by hematogenous spread, which leads to a cortical abscess or through ascending infection from the bladder, which primarily involves the medulla. [1],[2] The initial screening tool is renal ultrasonography.

We herewith report on a child with sickle cell anemia who was detected to have a renal abscess, which was treated successfully with antibiotics without the need for surgical intervention.


   Case Report Top


A five-year-old boy, born of a non-consan­guineous marriage, was a known case of sickle cell anemia "SS" type. He presented with a 10­days history of fever, cough and pain in the abdomen. There was no history of joint pain, seizures, loose motions, vomiting, urinary com­plaints, hematuria or previous blood trans­fusions. On physical examination, he had fever with temperature of 39.5°C, severe pallor, pulse rate of 98 per minute, respiratory rate of 32 per minute and blood pressure of 90/60 mmHg. There were no signs of dehydration. On abdo­minal examination, he had no hepatospleno­megaly. Crepitations were heard in both lung fields on respiratory examination while the other systemic examination was essentially normal. Initial laboratory investigations demons­trated hemoglobin of 6 gm/dL; white cell count of 56,200/mm 3 (65% neutrophils, 32% lym­phocyte), platelet count of 350,000/mm 3 and an erythrocyte sedimentation rate of 92 mm/ hour. Renal function tests and urinalysis were normal. A chest radiograph revealed bilateral lower lobe consolidation. The possibility of a sickle cell anemia-related vaso-occlusive crisis with lower respiratory tract infection was con­sidered and injectable crystalline penicillin and analgesics were started. Packed blood trans­fusions were administered to the child.

However, despite seven days of antibiotic therapy, fever persisted although the chest signs had resolved. Repeat white blood cell count was 32,000/mm 3 . Blood and urine cultures yielded no growth. Widal test was negative and the Mantoux test was non-reactive. The possibility of an occult abscess was con­sidered. An ultrasonography (USG) of the ab­domen revealed an enlarged left kidney with evidence of a hypoechoic collection measuring 4.6 × 3.2 × 2.9 cm (volume 24 mL) in the mid pole [Figure 1]. Computed tomography (CT) scan confirmed these findings. Intravenous ceftriaxone and amikacin were started. After 14 days of antibiotic therapy, the child became afebrile and repeat USG revealed only four mL collection. The patient was discharged and was advised to continue the antibiotics for a total of 21 days. On follow-up after two months, the child showed weight gain and USG revealed complete resolution of the renal abscess.


   Discussion Top


Sickle cell anemia is a common genetic dis­order, characterized by repeated hemolytic and vaso-occlusive crises which lead to wide­spread vascular occlusion and subsequent mul­tiple organ infarctions. The renal complications of sickle cell anemia include gross hematuria, renal infarction, papillary necrosis, nephrotic syndrome, urine concentration defects and me­dullary carcinoma of the kidney. [1],[2] The exact incidence of renal abscesses in children is not known and in a sickle cell child, it is not reported. Renal cortical abscess results from hematogenous spread and Staphylococcus aureus Scientific Name Search  is the common bacteria isolated whereas cor­tico-medullary abscesses usually follow ascen­ding infection from the urinary tract and are mainly caused by gram-negative organisms. [3],[4] Most of the abscesses are unilateral, and gene­rally occur in the right kidney. Abscess for­mation is more common in the renal cortex because of the richer blood and lymphatic supply and lower interstitial pressure.

Renal abscesses are very rare amongst intra­abdominal abscesses and the risk factors that are identified include presence of renal stone, structural abnormality of the urinary tract, his­tory of urologic surgery, trauma and diabetes mellitus. [5],[6],[7] No such risk factor was present in the our case.

To the best of our knowledge, this is the first case described in the literature in which renal abscess was present in a child with sickle cell anemia, in whom splenic abscesses are more common. The signs of renal abscess vary greatly and have no specific characteristics to aid in making the diagnosis. A child with renal abscess generally presents with fever, ano­rexia, weight loss and flank pain associated with leukocytosis and elevated erythrocyte se­dimentation rate. Physical examination is nor­mal most of time and on abdominal exami­nation, palpable masses are not consistent fin­dings. [7],[8] Ultrasound and computed tomography are the most valuable diagnostic tools, revea­ling a hypoechoic or hypodense mass. [9],[10] If loss of function in the affected kidney appears to be significant, a dimercaptosuccinic acid renal scan should be performed. In situations where the bacteremia is caused by S. aureus, vancomycin or clindamycin should be used in the initial empiric regimen. If urinalysis re­veals an obvious infection, cefotaxime, cef­triaxone, or ceftazidime plus aminoglycoside would be recommended. [10],[11] In our case, the renal abscess healed completely after giving antibiotics without the need for any surgical intervention. Generally, large intrarenal absce­sses require surgical drainage, particularly if the patient has persistent fever and absence of clinical improvement after one-week of appro­priate antimicrobial therapy. Renal abscesses may be drained percutaneously under CT or ultrasonographic guidance.


   Conclusion Top


This is the first reported case of a child with sickle cell anemia with renal abscess, who presented with fever and abdominal pain. For detecting the renal abscess, ultrasonography is the most useful tool and the management va­ries among different individuals.

 
   References Top

1.Wethers DL. Sickle cell disease in childhood: Part II. Diagnosis and treatment of major complications and recent advances in treatment. Am Fam Physician 2000;62(6):1309-14.  Back to cited text no. 1    
2.Dampier C, Setty BN, Eggleston B, et al. Vaso-occlusion in children with sickle cell disease: Clinical characteristics and biologic correlates. J Pediatr Hematol Oncol 2004;26 (12):785-90  Back to cited text no. 2    
3.Raynal G, Bracq A, Tillou X, Limani K, Petit J. Renal complications of sickle-cell anaemia. Prog Urol 2007;17(4):794-5.  Back to cited text no. 3    
4.Ataga KI, Orringer EP. Renal abnormalities in sickle cell disease. Am J Hematol 2000;63(4): 205-11.  Back to cited text no. 4    
5.Dembry LM, Andriole VT. Renal and perirenal abscesses. Infect Dis Clin North Am 1997; 11(3):663-80.  Back to cited text no. 5    
6.Higham M, Santos JI, Grodin M, Klein JO. Renal abscess without preexisting structural abnormality. Pediatr Infect Dis J 1984;3(2): 139-41.  Back to cited text no. 6    
7.Patterson JE, Andriole VT. Renal and perirenal abscesses. Infect Dis Clin North Am 1987;1 (4):907-8.  Back to cited text no. 7    
8.Dembry LM. Renal and perirenal abscesses. Curr Treat Options Infect Dis 2002;4:21-30.  Back to cited text no. 8    
9.Yen DH, Hu SC, Tsai J, et al. Renal abscess: Early diagnosis and treatment. Am J Emerg Med 1999;17(2):192-7.  Back to cited text no. 9    
10.Gonzales ET, Kaplan S. Renal abscess. In: Textbook of Pediatrics infectious disease.. Feigin RD, Cherry JD, Demmler GJ, Kaplan SL (eds). 5 th Edn, Saunders, Philadelphia 2004; 555-60.  Back to cited text no. 10    
11.Dalla PL, Pozzi-Mucelli F, Ene V. Medical treatment of renal and perirenal abscesses: CT evaluation. Clin Radiol 1999;54(12):792-7.  Back to cited text no. 11    

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Correspondence Address:
Amar M Taksande
Department of Pediatrics, Mahatma Ghandi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra-442102
India
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PMID: 19237820

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    Abstract
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