Clinical Pediatrics

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1Department of Pediatrics, New York Medical College and Westchester Medical .... Textbook of Pediatric Emergency Medicine,. 4th ed. Philadelphia: Lippincott.

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Urinary Tract Infection Presenting as an ALTE: Report of Three Cases Karen S. Edwards, Traci Gardner, Robin L. Altman and Donald A. Brand Clin Pediatr (Phila) 2004; 43; 375 DOI: 10.1177/000992280404300409 The online version of this article can be found at: http://cpj.sagepub.com

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Urinary Tract Infection Presenting as an ALTE: Report of Three Cases Karen S. Edwards, MD, MPH1,2 Traci Gardner, MD1 Robin L. Altman, MD1 Donald A. Brand, PhD1,2

Introduction

D

uring a 4-month period in 1999, 3 children admitted to our medical center after an apparent lifethreatening event (ALTE) were discharged with a diagnosis of urinary tract infection (UTI). This observation prompted us to consider the overlap between the presentation of a UTI and the symptoms that define an ALTE. An “apparent life-threatening event” is an episode that is frightening to the observer and characterized by some combination of apnea, color change, change in muscle tone or mental status, choking, or gagging.1 Discussions of the differential diagnosis in children presenting with an ALTE do not often include mention of urinar y tract infection. 2-10 The

present report describes the 3 cases of UTI that presented as ALTEs and reviews literature supporting a link between these two clinical entities.

agnosis was not suspected. All 3 patients responded well to antibiotics and had negative repeat urine culture results. None of the patients suffered another ALTE in the hospital.

Case Reports

Case 1 HISTORY

Between August and November 1999, 3 patients younger than 2 years of age admitted to The Children’s Hospital at Westchester Medical Center had experienced an ALTE shortly before or upon admission, were diagnosed with a UTI during the hospital stay, and, after undergoing an extensive evaluation, had no other identified condition that might have caused the ALTE. In 2 of the cases, UTI was considered because of fever or a history of UTI, but in the remaining case the di-

Clin Pediatr. 2004;43:375-377 1Department of Pediatrics, New York Medical College and Westchester Medical Center; 2Office of Undergraduate Medical Education and Primary Care, New York Medical College.

This study was supported in part by Health Resources and Services Administration award no. 1D12HP00022.

A 20-month-old girl, previously healthy, was taken by ambulance to a local hospital after an episode of unresponsiveness, limpness, and staring noted by the parent when the child did not wake at the usual time. When the child did not respond normally to stimulation, the parent called 911. The parent did not observe apnea, abnormal movements, or change in color. PHYSICAL EXAMINATION

At the referring hospital, the child was lethargic and euvolemic. She had normal vital signs and an otherwise unremarkable examination. On transfer to our institution she was alert and responsive, and her examination was remarkable only for nasal congestion and mild pharyngeal hyperemia. DIAGNOSTIC TESTS

Reprint requests and correspondence to: Karen Edwards, MD, MPH, Office of Undergraduate Medical Education and Primary Care, Munger Pavilion, New York Medical College, Valhalla, NY 10595. © 2004 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.

Initial blood glucose was 40 mg/dL, but this increased and remained normal on a regular diet. White blood cell count was 20,000

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Edwards et al. cells/mm 3. Serum electrolytes, blood culture, evaluation and culture of the cerebrospinal fluid, electroencephalogram, computed tomography scan of the head, magnetic resonance imaging (MRI) of the brain, and chest radiography were all normal. Urinalysis showed 10 to 15 wbc/hpf. On the second hospital day, the urine culture that had been collected by urethral catheterization at the referring hospital grew >12,000 CFU/mL of group D enterococcos. Complete evaluation for etiologies of hypoglycemia was negative.

Case 2 HISTORY

A 7-month-old girl was hospitalized for evaluation of dusky lips and face, cold extremities, and shallow breathing noted by the mother when the child started to cry after 2 hours of sleep. She was responsive to her mother’s voice. The child remained dusky for approximately 5 minutes. She had been ill with 5 days of dry cough, 3 days of fever, and 1 episode of vomiting on the day of admission. There was no history of apnea, limpness, or abnormal movements. PHYSICAL EXAMINATION

Temperature was 102.2°F, heart rate 180 beats per minute, respiratory rate 36 breaths per minute, and oxygen saturation 96% on room air. The physical examination was otherwise normal.

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Case 3 HISTORY

A 3-month-old girl was transferred to our hospital for further evaluation of a 15-minute episode of cyanosis that occurred at the referring hospital soon after admission for a 1-day history of fever and decreased appetite. The episode was noticed by the mother when the child started to cry while in bed 25 minutes after a feeding. Oxygen saturation was as low as 85% in room air and the capillary refill was sluggish. There was no apnea, choking, or abnormal movement. There was no history of nasal congestion, cough, respiratory distress, vomiting, or diarrhea. The patient had a history of UTI 1 month before admission after which a renal/bladder ultrasound and voiding cystourethrogram were normal. PHYSICAL EXAMINATION

Unremarkable except for a low-grade fever. DIAGNOSTIC TESTS

Complete blood cell count, serum electrolytes, liver function tests, blood culture, evaluation and culture of cerebrospinal fluid, electroencephalogram, brain MRI, and chest radiograph were all normal. The urine culture obtained by urethral cathetization grew >100,000 CFU/mL of Escherichia coli.

DIAGNOSTIC TESTS

Discussion

Complete blood cell count, serum electrolytes, liver function tests, blood culture, evaluation and culture of cerebrospinal fluid, electroencephalogram, brain magnetic resonance imaging, and chest radiography were all normal. The urine culture obtained by urethral catheterization grew >100,000 CFU/mL of Escherichia coli.

The clinical presentation of a child who has experienced an ALTE varies from asymptomatic to severely ill. The most common f inal diagnoses are gastroesophageal reflux, seizures, and lower respiratory infections, although a variety of other etiologies have also been implicated.

Descriptive studies of children presenting with ALTEs differ in the proportion of patients discharged with specific diagnoses. For example, the reported proportion of patients discharged with gastoresophageal reflux ranges from 5% to 72%, the proportion with seizures from 4% to 20%, and the proportion with infectious conditions from 0% to 31%.11-15 This variability may have occurred because of different inclusion criteria, diagnostic protocols, and definitions of an ALTE used in the different studies. In a large proportion of ALTEs, an etiology is never determined. One study reported that 70% of ALTE cases were discharged as “idiopathic.”11 These cases may have included some patients whose underlying diagnoses were missed because pertinent tests were not performed. When evaluating an ALTE, physicians may choose to include diagnostic studies to detect infections based on age and clinical presentation. A clinician may be less likely to consider infection in an older infant who is afebrile and well-appearing on admission. While such practices would seem to be reasonable, current published guidelines for evaluating an ALTE do not offer a standardized approach to the diagnosis of infectious etiologies. Recognized infectious etiologies include pertussis14,16 and viral respiratory infections, especially those caused by the respiratory syncitial virus. 8,17,18 Published ALTE case series have noted a few patients with UTI,12,14-16 but this etiology is not specifically mentioned in most discussions of the differential diagnosis of an ALTE.2-10 In a survey of chief residents from 131 pediatric residency programs that asked about the diagnosis and management of

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U r i n a r y Tr a c t I n f e c t i o n a n d A LT E a hypothetical case of ALTE, none of the residents mentioned UTI in the differential diagnosis or suggested urine culture as part of the evaluation.19 Suggested strategies for evaluating an ALTE that recommend urine culture only in the presence of specif ic clinical indications6,7,9,10 fail to consider the often nonspecific or subtle presentations of a UTI in infants and young children. These presentations include fever without source, and nonspecific behavioral and gastrointestinal symptoms. A causal link between UTI and ALTE is certainly plausible. Other serious infections sometimes result in cardiorespiratory instability manifesting as apnea or color change, altered level of consciousness, or change in muscle tone. For example, rotavirus and respirator y syncitial virus infections have been accompanied by bradycardia and apnea.17,18,20 A plausible pathophysiologic pathway between UTI and ALTE might be mediated by the autonomic nervous system and inflammator y substances. The high frequency of ALTE discharges without a confirmed etiologic diagnosis, broad spectrum of clinical presentations of UTI, and plausibility of a pathophysiologic link between UTI and ALTE together suggest the need to consider obtaining a urine culture in a patient presenting with an ALTE if the initial clinical findings do not suggest another cause. Such a strategy could increase the detection of a treatable

disease and decrease the number of ALTE patients discharged without a diagnosis.

REFERENCES 1. Infantile Apnea and Home Monitoring. NIH Consensus Statement 1986;6(6):1-10. 2. Barkin RM, Gausche-Hill M. Sudden infant death syndrome. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed. St. Louis: Mosby; 2002:2393-2395. 3. Brooks JG. Apparent life threatening events and apnea of infancy. Clin Perinatol. 1992;19(4):809-838. 4. Brooks JG. Apparent life-threatening events. Pediatr Rev. 1996;17(7). 5. Kelly DH. Apnea of infancy. In: Dershewitz RA, ed. Ambulatory Pediatric Care, 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 1999:830-834. 6. Torrey SB. Apnea. In: Fleisher GR, Ludwig S, Henretig FM, et al, eds. Textbook of Pediatric Emergency Medicine, 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2000:147-151. 7. Perkin RM, Swift JD, Baron H, Downey III R. Apparent life-threatening events: recognition, differentiation, and managment. Pediatr Emerg Med. 1998;3(11):99-110. 8. Loughlin GM, Carroll JL. Apparent life threatening events. In: McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB, eds. Oski’s Pediatrics—Principles and Practice, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999:589-596. 9. McCollough M, Sharieff GQ. Common complaints in the first 30 days of life. Emerg Med Clin Nor th Am. 2002;20(1). 10. Farrell PA, Weiner GM, Lemons JA, Altemeier IWA. SIDS, ALTE, apnea, and the use of home monitors. Pediatr Rev. 2002;2(1).

11. Sankaran K, McKenna A, O’Donnell Mea. Apparent life threatening prolonged infant apnea in Saskatchewan. West J Med. 1989;150:293-295. 12. Simpson H, MacFadyen U, Paton J. “Near-miss” or “near-myth” for sudden infant death syndrome? clinical observations on 57 infants. Aust Paediatr J. 1986:47-51. 13. Rahilly P. Review of “near-miss” sudden infant death syndrome and results of simplified pneumographic studies. Aust Paediatr J. 1986:53-54. 14. Kahn A, Blum D. Home monitoring of infants considered at risk for sudden infant death syndrome. Eur J Pediatr. 1982;139:94-100. 15. Davies F, Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emerg Med J. 2002;19(1):11-16. 16. Gray C, Davies F, Molyneux E. Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care. 1999;15(3):195199. 17. Church NR, Aana NG, Hall CB, Dobson S. Respiratory syncytial virus-related apnea in infants. demographics and outcomes. AJDC. 1984;138:247250. 18. Naulaers G, Debaene K, Daniels H, Deroost F, Devlieger H. Apneas on polysomnography as a first sign for RSV-bronchiolitis. Pediatric Res. 1999; 45(5):18A. 19. Hickson GB, Cooper WO, Campbell PW, Altemeier IWA. Effects of pediatrician characteristics on management decisions in simulated cases involving apparent life-threatening events. Arch Pediatr Adolesc Med. 1998; 152(4):383-387. 20. Reidel F, Kroener T, Stein K, Nuesslein T, Reiger C. Rotavirus infection and bradycardia. Eur J Pediatr. 1996;155:36-40.

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