CASE REPORT |
https://doi.org/10.5005/jp-journals-10081-1430 |
Optimizing Treatment Strategies in a Pediatric Infectious Case: A Multidisciplinary Perspective
1Department of Microbiology, LMMF’s Mai Mangeshkar Hospital, Pune, Maharashtra, India
2,3Department of Paediatrics, LMMF’s Mai Mangeshkar Hospital, Pune, Maharashtra, India
Corresponding Author: Komal R Mirlekar, Department of Microbiology, LMMF’s Mai Mangeshkar Hospital, Pune, Maharashtra, India, Phone: +91 9561748458, e-mail: komal.mirlekar@gmail.com
Received: 23 March 2024; Accepted: 01 May 2024; Published on: 05 November 2024
ABSTRACT
This case study presents the comprehensive evaluation and management of a 4-year-old male patient with phimosis who presented with fever, anorexia, weakness, and burning micturition. Upon admission, bilateral multiple renal abscesses and cystitis were diagnosed through ultrasound examination, prompting initiation of intravenous (IV) piperacillin–tazobactam combination and IV vancomycin. Due to concerns of red man syndrome, vancomycin was closely monitored, and a multidisciplinary approach involving specialists in pediatric infectious diseases and surgery was adopted. Sensitivity testing revealed Escherichia coli infection resistant to multiple antibiotics, leading to a switch to IV meropenem. Additional investigations for suspected mumps yielded negative results, emphasizing the importance of thorough evaluation. The patient’s condition improved with appropriate antibiotic therapy, as evidenced by decreasing abscess size and resolution of symptoms. This case underscores the significance of tailored antibiotic therapy, close monitoring, and multidisciplinary collaboration in managing complex pediatric infectious cases, ensuring optimal patient outcomes. Additionally, the patient’s complete vaccination highlights the potential for atypical mumps presentations. Resurgence factors include secondary vaccine failure, reduced vaccine effectiveness (85–90%), and lack of natural boosting from wild-type virus.
Keywords: Case report, E. coli, Extended spectrum beta-lactamase, Mumps, Red man syndrome, Renal abscess, Urinary tract infection
How to cite this article: Mirlekar KR, Mahajan KD, Rakshe SA. Optimizing Treatment Strategies in a Pediatric Infectious Case: A Multidisciplinary Perspective. Pediatr Inf Dis 2024;6(4):134–137.
Source of support: Dr Sangeeta Joag, Laboratory Head, LMMF’s Mai Mangeshkar Hospital, Pune, Maharashtra, India; Dr Vinayak Nanekar, Consultant Radiologist, LMMF’s Mai Mangeshkar Hospital, Pune, Maharashtra, India.
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.
INTRODUCTION
The management of pediatric cases presenting with complex symptoms requires a comprehensive approach to ensure timely diagnosis and effective treatment. Undetected urinary tract infections (UTIs) can escalate into serious complications, especially in pediatric patients, where they may manifest as renal abscesses. This case study delves into the journey of a 4-year-old boy whose initial symptoms of fever, loss of appetite, weakness, and discomfort while urinating went unnoticed. Unfortunately, the untreated UTI progressed to renal abscesses and further complications. This case sheds light on early detection and diagnosis of UTIs in children to avert severe consequences. Highlighting the significance of timely intervention, it emphasizes how urine routine microscopy (URM), if conducted promptly, serves as a crucial tool in preventing complications. By illuminating the importance of vigilance and proactive screening measures, this case advocates for enhanced healthcare protocols focused on early identification and management of UTIs in pediatric patients.
CASE DESCRIPTION
A 4-year-old male patient with phimosis presented with symptoms of fever, anorexia, facial swelling, weakness, and burning micturition. The fever had been intermittent for 2 weeks prior to admission, during which the patient had received cefixime and co-amoxiclav as outpatient treatment.
Upon admission, the patient’s vital signs were normal, complete blood count was within normal limits but a C-reactive protein (CRP) test showed raised levels of 125. The patient remained hemodynamically stable throughout the presentation of symptoms indicating a reassuring aspect of his clinical status. Blood and urine cultures were sent immediately before starting the antibiotics. An ultrasound of the abdomen revealed cystitis with bilateral multiple renal abscesses of varying sizes in both kidneys. A urine analysis showed the presence of 10–15 pus cells/hpf and proteins.
The patient was started on intravenous (IV) piperacillin–tazobactam combination with IV vancomycin and a pediatric infectious disease physician was consulted. Post IV antibiotics, the child presented with mild facial puffiness, pruritus, and an erythematous rash spreading across the face, neck, upper torso, alongside pedal edema, all indicative of red man syndrome, a recognized adverse effect associated with vancomycin administration. Each vancomycin dose was then administered cautiously over 2 hours to mitigate red man syndrome and oral hydroxyzine added to manage clinical symptoms effectively.
A computed tomography (CT) abdomen was recommended as a follow-up and strict monitoring of urine output was advised. The patient was continued on piperacillin–tazobactam combination and vancomycin, also referred to a pediatric surgeon.
The pediatric surgeon suggested repeating the ultrasonography of kidneys, ureters, and bladder (USG-KUB) if the fever persisted and considering a change in antibiotics depending on the urine culture reports.
On day 2 of admission, the patient’s facial swelling increased, but complete blood count (CBC) results were within normal limits. The CRP had dropped down to 44. The urine culture showed the presence of Escherichia coli, with a colony count of <1000 CFU/mL, which was sensitive to amikacin, gentamicin, imipenem, meropenem, fosfomycin, and nitrofurantoin. The strain was resistant to co-amoxiclav, piperacillin–tazobactam combination, cefoperazone–sulbactam, trimethoprim–sulfamethoxazole, all four generations of cephalosporins and fluoroquinolones. The decision to continue vancomycin was made based on the low colony count observed in the urine culture. The patient was switched to IV meropenem 8 hourly based on the sensitivity report which was resistant to piperacillin–tazobactam due to persistent fever spikes and no clinical improvement. The repeat ultrasonography (USG) showed no change in abscess size.
On day 3 of admission, the patient’s right parotid swelling and facial swelling increased; hence, IV fluids were omitted. The child was also isolated from other patients, in view of suspected mumps. However, the patient had no fever on days 4 and 5, and also, the parotid swelling reduced. Blood urea nitrogen, liver function tests, and creatinine levels were within normal limits. In view of right parotid swelling, a throat swab and urine were sent for polymerase chain reaction (PCR) testing to the National Institute of Virology in Pune. Here, mumps was also considered a potential diagnosis due to the ongoing epidemic in the city, adding a layer of complexity to the diagnostic process.
On day 6, the patient experienced a low-grade fever spike of 100.3, and a USG of the neck was advised. The USG revealed increased vascularity in the right parotid and submandibular glands, as well as reactive cervical lymphadenopathy on both sides, indicating an active infective/inflammatory etiology. The final blood culture report showed no growth.
On day 7, the patient experienced persistent fever spikes and pain. The National Institute of Virology (NIV) PCR report came back negative for mumps. Next day, the patient was mildly febrile and a repeat USG of the abdomen showed a decrease in the size and number of abscesses in the left kidney and no abscesses in the right kidney. The CRP level was 18.
On day 9, the patient was afebrile, and the parotid swelling reduced. IV vancomycin was discontinued after 10 days, while IV meropenem was maintained every 8 hours on an outpatient basis to fulfil the full 14-day course, owing to financial constraints. The patient was discharged after 10 days of hospitalization (Figs 1 to 3).
Fig. 1: Ultrasonography neck suggestive of bulky right parotid and submandibular glands in favor of acute inflammatory/infective etiology
Fig. 2: Ultrasonography of abdomen suggestive of bilateral renal abscesses
Fig. 3: Ultrasonography of abdomen posttreatment, suggestive of resolving nature of abscesses
CONCLUSION AND CLINICAL SIGNIFICANCE
The significance of this case study lies in the comprehensive evaluation and management of a pediatric patient presenting with multiple symptoms and potential complications. The prompt identification of bilateral renal abscesses, cystitis, and facial swelling highlights the importance of utilizing appropriate diagnostic tools such as ultrasound and laboratory tests like blood cultures and urine analysis. Vancomycin, meropenem, and piperacillin–tazobactam combination were initiated due to the prevalence of E. coli and Staphylococcus aureus, which are the most common organisms implicated in renal abscesses.1-4Additionally, considering the high prevalence of extended-spectrum beta-lactamase (ESBL)-producing E. coli and methicillin-resistant Staphylococcus aureus (MRSA) in the local Indian context, this antibiotic regimen was chosen.5-8
On the 2nd day, the child’s CRP levels notably decreased to 44, indicating a positive response to treatment. However, despite this improvement, fever spikes persisted, and there was no observed change in the dimensions of the abscesses as confirmed by ultrasonography findings. Consequently, in light of these clinical indications, the decision was made to escalate antibiotic therapy to meropenem. The plausible explanation for this decrease in CRP is that it likely signifies the waning bacterial activity, occurring concurrently with the onset of a superimposed mumps infection caused by the paramyxovirus.
The clinical presentation proved invaluable in excluding the differential diagnosis of acute bacterial parotitis. While the glands were tender upon palpation, the absence of erythema or warmth in the overlying skin contrasted with typical findings in acute bacterial parotitis. Furthermore, the patient’s age aligned with a higher likelihood of mumps, reinforced by the ongoing epidemic in the city.
By involving specialists in pediatric infectious diseases and surgery, the patient received tailored antibiotic therapy based on sensitivity reports, ensuring effective treatment for the underlying E. coli infection. The multidisciplinary approach also allowed for close monitoring of potential side effects, such as red man syndrome associated with vancomycin, and the timely adjustment of medication to ensure the patient’s safety and well-being.
This case study emphasizes the need for ongoing monitoring and follow-up to assess the efficacy of treatment. The repeated ultrasound evaluations provided valuable insights into the reduction in abscess size and absence of abscesses in the kidneys. The resolution of symptoms, such as fever, facial swelling, and parotid swelling, further demonstrates the effectiveness of the chosen treatment approach.
Prioritizing URM in febrile pediatric patients is crucial due to its rapidity and effectiveness in providing valuable insights into their condition. URM serves as a swift diagnostic tool that aids healthcare professionals in promptly identifying potential UTIs or other urinary abnormalities. Early URM also serves to mitigate the risk of further complications, emphasizing the importance of timely diagnostic measures in pediatric patients.9
Here, it is noteworthy that the patient had received complete vaccination, which underscores the significance of considering atypical presentations of mumps. The resurgence of mumps has been attributed to several factors, including secondary vaccine failure stemming from the waning of vaccine-induced immunity. Additionally, increased susceptibility may arise due to the absence of natural boosting from circulating wild-type mumps virus. Notably, the mumps vaccine’s effectiveness, ranging from 85 to 90% is comparatively lower than that of measles and rubella vaccines. These factors collectively contribute to the complexity of mumps epidemiology and highlight the importance of recognizing and addressing atypical presentations in vaccinated individuals.10,11
Furthermore, this case raises awareness about the importance of thorough evaluation in cases where symptoms do not align with initial diagnoses. In this instance, though the patient showed clinical mumps, the PCR done gave a negative report, prompting further investigations to identify the true cause of the patient’s symptoms. The sensitivity of reverse transcription polymerase chain reaction (RT-PCR) on buccal swabs, urine specimens, and IgM serology stands at 79, 43, and 25%, respectively, underscoring the potential for false-negative results. Similarly, the specificity of RT-PCR on buccal swabs, urine specimens, and immunoglobulin M (IgM) serology demonstrates high values of 99.5, 100, and 99.7%, respectively, minimizing the likelihood of false-positive outcomes. This discrepancy between sensitivity and specificity focusses the inherent challenges in diagnostic testing and the importance of clinical judgment in correlation with laboratory findings. This highlights the necessity for healthcare providers to carefully interpret test results, taking into account both the clinical presentation and the accuracy of the diagnostic tests.12
Overall, this case emphasizes the clinical significance of a multidisciplinary approach, appropriate diagnostic investigations, tailored antibiotic therapy, and vigilant monitoring in the effective management of complex pediatric cases. It highlights the importance of ongoing evaluation and adjustments in treatment plans to ensure optimal patient outcomes.
ORCID
Komal R Mirlekar https://orcid.org/0009-0005-7703-2611
Keyur D Mahajan https://orcid.org/0000-0001-5738-1818
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