Sterile Pyuria in Kawasaki Disease: A Large Prospective Cohort Study.

Background: Kawasaki disease (KD) is an acute systemic vasculitis and is becoming the leading cause of acquired cardiac disease in Children. Sterile pyuria is a known complication of KD. However, its associations with the inflammatory reaction severity, IVIG resistance as well as coronary artery lesions (CALs) in KD remain elusive. Aims: We aimed to analyze the clinical profiles of sterile pyuria in KD, to determine whether sterile pyuria is an indicator of the disease severity in patients with KD, and to assess the associations between sterile pyuria and IVIG resistance as well as CALs. Methods: We prospectively collected data from 702 patients with KD between January 2015 and June 2020. Profiles of patients with sterile pyuria (group A, n = 63) were compared to those of patients without sterile pyuria (group B, n = 639). The associations between sterile pyuria and IVIG resistance as well as CALs in KD were further determined by univariate and/or multivariate logistic regression analysis. Results: Sterile pyuria was observed in 9.0% of patients with KD, without predominance in age spectrum and gender. The levels of neutrophil percentages, alanine transaminase, total bilirubin, blood urea nitrogen, creatinine, the incidence of initial IVIG resistance, and rate of moderate/giant coronary artery aneurysms (CAAs) were significantly higher in group A than that in group B. Sterile pyuria was identified as an independent risk factor for initial IVIG resistance, yielding high specificity (92.7%) and low sensitivity (18.5%). However, sterile pyuria was not associated with repeated IVIG resistance and persistence of CALs in KD. Conclusion: The incidence of sterile pyuria is relatively low in KD patients. Patients with sterile pyuria in KD exhibited a more severe inflammatory burden and were more likely to develop the initial IVIG resistance and moderate/giant CAAs. The overall prognosis of KD patients with sterile pyuria was satisfactory.

Kawasaki disease in Malaysia: Biochemical profile, characterization, diagnosis and treatment.

Introduction: Kawasaki disease (KD) is an acute idiopathic systemic vasculitis with a self- limiting course that predominantly affects children under 5 years old, particularly in the East Asian countries. Nevertheless, to date, the data on KD in Malaysia are limited. This study aimed to evaluate the epidemiology, clinical features, treatment, and outcomes of KD among the pediatric patients admitted to Hospital Canselor Tunku Muhriz (HCTM), Kuala Lumpur, Malaysia. Method: A retrospective cohort study of 66,500 pediatric patients presented at HCTM from the year 2004 to 2021 was conducted. Results: 62 KD cases out of 66,500 pediatric admissions were reported, with a male-to-female ratio of 1.58 to 1. Majority of KD patients (95.0%) were younger than 5 years old. Prior infection was reported in 5 KD patients (8.1%). Apart from the classical features, manifestations of various organ systems including cardiovascular (16.1%), gastrointestinal (43.5%), neurological (1.61%), musculoskeletal (1.61%), and genitourinary (17.7%) systems were observed. There was a significant association between sterile pyuria and coronary artery aneurysm (CAA) (p < 0.05). Interestingly, abnormal liver parameters (p < 0.05) and incomplete KD (p < 0.05) were significantly related to IVIG resistance. Discussion: The presence of family history, immunological disorder, and previous infection in our KD patients suggested that there is a possibility of genetic, immunological, and infectious roles in the pathophysiology of KD. IVIG resistance is more likely to occur in KD patients with hepatic dysfunction or incomplete KD presentation. These findings highlighted the significant contribution of laboratory parameters to the prognosis of KD, prompting more in-depth research on the KD scoring systems and their relevance in this country.

Acalculous Cholecystitis in a Seven-Year-Old Girl With Epstein-Barr Virus Infection.

Epstein-Barr virus (EBV) infection with associated acute acalculous cholecystitis (AAC) has been reported in 18 pediatric patients. Our case is that of a seven-year-old girl with acute EBV infection and associated AAC.

Disseminated Mycobacterium abscessus subspecies massiliense infection and subsequent prosthetic joint infection in a hemodialysis patient: A case report.

A 74-year-old man with diabetic nephropathy undergoing dialysis after total knee arthroplasty presented to our hospital with dyspnea and abnormal behavior such as wearing his pants on his head. The patient was in shock with ventricular tachycardia. Urine and blood cultures showed MAM with sterile pyuria. We administered amikacin and imipenem cilastatin, but repeated cultures were persistently positive. Although we initially chose not to administer azithromycin because of a higher risk of fatal arrhythmia, we had no choice but to administer azithromycin because of treatment failure. Upon close monitoring, we observed no arrhythmia, and the blood cultures became negative. The patient was discharged on day 106 without any symptoms. However, 2 months after discontinuation of antibiotics, he was readmitted and diagnosed with prosthetic joint infection due to MAM. He could not undergo total knee arthroplasty resection because of his low tolerance to surgery. We re-administered same antibiotics, and repeated draining and cleaning of his left knee for several weeks. The inflammation in the knee joint gradually improved, and the patient was discharged while treatment with azithromycin and amikacin was continued. After being discharged, the patient did not experience recurrent disease for at least 6 months. Our case suggests that MAM can cause sterile pyuria and infection in a patient with diabetic nephropathy. The macrolide agent is a key drug for MAM infection, and repeated joint lavage in addition to administering antibiotics may be an alternative treatment for prosthetic joint infection in patients with intolerance to surgery.

The Differential Diagnosis of Sterile Pyuria in Pediatric Patients: A Review.

Sterile pyuria is a common finding in pediatric patients. Literature describing the diagnoses as well as clinical characteristics of children with sterile pyuria is lacking. This review was performed to establish an evidence-based approach to the differential diagnosis by way of an extensive literature search. The definition of pyuria is inconsistent. The various causes of pediatric sterile pyuria identified were classified as either Infectious or Non-Infectious. Sub-categories of Infectious causes include: Viral Infection, Bacterial Infection, Other Infections (tuberculosis, fungal, parasitic), Sexually Transmitted Infections, Recent Antibiotic Therapy. Non-Infectious causes include: Systemic Disease, Renal Disease, Drug Related, Inflammation adjacent to Genitourinary Tract. Clinicians that encounter pediatric patients with sterile pyuria and persistent symptoms should consider the substantial differential diagnosis described in this study.

Drug-induced cystitis caused by herbal medicine (Bofutsushosan).

Bofutsushosan (BTS), one of many traditional Japanese medicines (Kampo medicines) is attracting attention for obesity and metabolic syndrome. We report allergic cystitis caused by 8-year BTS usage in a 70-year-old female. The patient presented with micturition pain with sterile pyuria over a 3-month period. Cystoscopy showed diffuse urothelial erythema and edema. Urine cytology specimens showed increased eosinophilic cells. By discontinuing BTS, the cystitis symptoms disappeared after 4 days, and urinalysis normalized. Resuming BTS without physician approval resulted in cystitis symptoms and after cessation the symptoms rapidly subsided. This is the first English case report linking allergic cystitis to herbal medicine.

Introduction of a complementary screening system for the detection of sexually transmitted infections in patients with sterile pyuria.

OBJECTIVE: The aim of the study was to evaluate a complementary screening system for the detection of sexually transmitted infections in patients with sterile pyuria. METHODS: A prospective study was conducted using Real-time multiplex qPCR in 300 consecutive urine samples with data on sterile pyuria. STI prevalence and patient epidemiological data were analyzed. RESULTS: A total of 29 positive cases (9.67%) were found: 16 Chlamydia trachomatis, 5 Mycoplasma genitalium, 5 Trichomonas vaginalis and 3 co-infections. The group with sexually transmitted infections was mainly composed of women (65.5%), of which one third was pregnant. CONCLUSIONS: This study presents an effective screening system for the detection of sexually transmitted infections that can be integrated into the laboratories' work routine.

Assessment of asymptomatic bacteriuria and sterile pyuria among antenatal attendants in hospitals in northern Ghana.

BACKGROUND: Asymptomatic bacteriuria (ASB) and sterile pyuria (SP) are complexities of UTI whose prevalence are not known in the northern sector of Ghana. Our aim was to determine the occurrence of sterile pyuria and asymptomatic bacteriuria among pregnant women accessing antenatal care at a secondary and tertiary care hospitals in Tamale, northern Ghana. METHODS: A cross sectional study was conducted by screening 530 pregnant women with no signs of acute urinary tract infection attending antenatal clinic for a period of 6 months. Midstream urine was collected for microscopy, quantitative urine culture and antibiotic susceptibility testing. Data analysis was carried out using the Statistical Package for Social Sciences version 20. RESULTS: Asymptomatic bacteriuria was respectively 20 and 35.5% at Tamale Central and Tamale Teaching Hospital out of the 390 and 90 women screened. Sterile pyuria was found among 66% of the 50 women presenting at Tamale Central Hospital. More than 64% of isolates recovered from ASB patients were S. aureus and coagulase negative Staph. (CoNS). Escherichia coli was the dominant species among members of the enterobacteriaceae isolated. Highest susceptibility was recorded against gentamicin and amikacin while most resistance was to Ampicillin, cotrimoxazole, chloramphenicol and nitrofurantoin. Resistance to imipenem and vancomycin were 28.8 and 52%, with strains showing multiple drug resistance of between 81 and 92%. CONCLUSION: The prevalence of asymptomatic bacteriuria is appreciably higher (20-35.5%) than documented rates in the southern sector of the country. The presence of sterile pyuria which may be an indication of asymptomatic renal impairment and most often overlooked in antenatal management is 66%. Empirical treatment of UTIs at the Tamale Central and Teaching Hospital without confirmation of susceptibility may result in treatment failure. It is necessary to screen and treat pregnant women for ASB and SP due to the complications associated with these conditions.

Is sterile pyuria another minor diagnostic criterion in urinary tuberculosis?

INTRODUCTION: Composite reference standard (CRS) is used for diagnosis of urinary tract tuberculosis (UTB). We examined if addition of a new 'component test' as minor criterion in the form of SP could improve the yield. METHODS: We identified patients admitted with a diagnosis of UTB from January 2009 to February 2016 from our patient database. We performed the validation of addition of a new 'component' "sterile pyuria" to the existing basic CRS. RESULTS: SP was seen in 50 patients (65.7%). Forty (52.6%) of these patients had one major criterion positive and 10 (13.1%) were diagnosed based on minor criteria. If SP was added as a minor criterion, an additional 8 (9.2%) patients would have been diagnosed based on minor criteria alone without the need for a histopathology. CONCLUSIONS: SP could improve the diagnostic yield of existing CRS by 8% with a 70% decrease in reliance on histopathology for diagnosis.

Disseminated Mycobacterium avium Infection Presenting with Bladder Lesions in a Patient with Interferon-γ-neutralizing Autoantibodies.

A 63-year-old woman presented with a fever, eruption, and sterile pyuria. A cystoscopic examination revealed submucosal nodular lesions in the trigone of the bladder, and a biopsy specimen showed epithelioid cell granulomas in the lamina propria of the bladder. Mycobacterium avium grew in the urine culture. Other organ involvement, such as the lungs, spleen, bones, muscles, and pelvic lymph nodes, was observed on radiological examinations, and M. avium was isolated from some organ lesions. Interferon-γ-neutralizing autoantibodies were detected in the patient's serum. Therefore, the patient was diagnosed with disseminated M. avium infection, which was resolved with antimycobacterial treatment.

Does pyuria always suggest urinary tract infection with common microorganisms? Questions.

Genitourinary system tuberculosis (GUTB) is a chronic granulomatous infection in which tuberculous bacilli affect one or more organs in the genitourinary system. In this report, an unusual presentation of miliary tuberculosis was presented as GUTB. A 15-year-old girl presented with complaints of severe abdominal pain and dysuria. Abdominal examination showed tenderness and defense. Pyuria and microscopic hematuria were observed. Acute abdominal causes could not be excluded through abdominal ultrasound. On abdominal computed tomography, a necrotic lesion was detected in the right kidney. Acid-fast bacilli were detected in the urine. Quartet anti-tuberculosis therapy was started. After treatment, static renal scintigraphy with 99mTc-dimer captosuccinic acid and single-photon emission CT imaging showed parenchymal injury. In any suspected patient, voiding symptoms, abdominal or flank pain, sterile pyuria, and hematuria should be kept in mind as the presenting manifestations of GUTB in the differential diagnosis.

Sterile pyuria: a forgotten entity.

Sterile pyuria is a common entity. Yet there are no guidelines to address this issue. We have conducted a systematic review over 20 years and reviewed the results. Guidelines for assessment, diagnosis and management are developed based on these results.

Pyuria in patients with Kawasaki disease.

Kawasaki disease (KD) is an acute, febrile vasculitis that predominantly develops in children ≤ 5 years of age and can lead to multiple organ injuries including the kidneys. Of these injuries, pyuria is a common feature of patients with KD, occurring in 30%-80% of patients. Sterile pyuria is most common in KD patients ≤ 1 year of age. KD patients with sterile pyuria exhibit more severe inflammatory reactions and may have sub-clinical renal injuries. Sterile pyuria in KD is associated with mononuclear cells (not neutrophils) in the urine. Although sterile pyuria in KD was at one time thought to be due to urethritis caused by a non-specific vasculitis of the urethra, recent studies suggest that sterile pyuria in KD originates from the urethra, the kidney as a result of mild and sub-clinical renal injuries, and/or the bladder due to cystitis. Pyuria is not always sterile in KD, but can result from a urinary tract infection (UTI). As causative pathogens, Escherichia coli and Klebsiella oxytoca have been reported. The clinical phenotypes do not differ between those with or without UTI. Because some KD patients with UTIs have urinary tract abnormalities such as vesicoureteral reflux, a complete UTI workup including renal ultrasound, voiding cystourethrogram and/or dimercaptosuccinic acid renal scan recommended in KD patients with UTIs.

Changes in urine levels of substance P, vasoactive intestinal peptide and calcitonin-gene-related peptide in patients with urinary tract infections.

Urinary tract infections (UTI) are important health problems and predisposing causes of UTI are not entirely known. Neuro-immune interactions play an important role in human health and disease. Capsaicin-sensitive sensory nerves which in nerve bladder extensively regulate immune system through neuropeptides such as substance P (SP), calcitonin-gene related peptide (CGRP) and vasoactive intestinal peptide (VIP). In addition these neuropeptides also have anti-bacterial effects. To determine how the levels of these peptides changes during UTI, 67 patients (50-90 years-old) diagnosed with UTI in Akdeniz University Faculty of Medicine Hospital were compared with 37 healthy people 50 years or older as the control group. Additionally, 7 patients with UTI symptoms (dysuria, urgency) but with sterile pyuria were also included in the study. Urine samples from 15 patients, whose symptoms regressed with control urine cultures being sterile, were taken after completion of the treatments. Urine neuropeptide levels were determined by ELISA. CGRP levels are significantly higher in patients with UTI, but did not associate with pyuria whereas SP and VIP levels were significantly lower in patients with sterile pyuria, indicating sensory nerve deficiency. Since CGRP exerts immunosuppressive effects, increased levels of the peptide may predispose to UTI. Furthermore, the connection between the observed sensory nerve deficiency and sterile pyuria warrants further studies.

Pyuric diabetic patients: A tertiary centre experience from Karachi.

OBJECTIVES: (1) To determine frequency of urinary tract infection among pyuric diabetic patients. (2) To determine sterile pyuria frequency among pyuric diabetic patients. (3) To determine factors predisposing to urinary tract infection. METHODS: This is a non randomized, prospective observational study done in tertiary care set up of Dow University of Health Sciences, Karachi. Data collection done from June 2013 till August 2013. Sampling was done by convenient method, sample size of 97. Inclusion criteria was all adult (above 16) patients with diabetes mellitus and pyuria (more than 4 pus cells /HPF) whose urine culture report was also available. Verbal consent was sought from patients. All data was collected on a Performa. Data was maintained and analyzed on SPSS version 16. RESULTS: Total number of pyuric diabetic patients in study was 97. Frequency of Urinary tract infection was 59/97 (60.82%), prevalence of culture negative sterile pyuria was found 38/97 (39.17%). Urinary tract infection was found to be more in females with lower urinary tract symptoms and flank pains. Stone disease, obstructed pelvicalyceal system, proteinuria, high serum creatinine and positive nitrites were found more in culture positive patients than in culture negative pyuric patients. CONCLUSIONS: Pyuric diabetic patients in our study population were found to have culture positive UTI in 60.82% and culture negative sterile pyuria among 39.17% of patients. UTI was found more in females, in symptomatic patient and with abnormal urinary tract anatomy and function.

Clinical characteristics of Kawasaki disease with sterile pyuria.

PURPOSE: Kawasaki disease (KD) is a systemic vasculitis and affects many organ systems. It often presents sterile pyuria, microscopic hematuria, and proteinuria due to renal involvement. The aims of this study were to define clinical characteristics of acute KD patients with pyuria and to analyze meaning of pyuria in KD. METHODS: The medical records and laboratory findings including serum and urine test of 133 patients with KD admitted to Yeungnam University Hospital from March 2006 to December 2010 were reviewed retrospectively. RESULTS: Forty patients had sterile pyuria and their clinical characteristics including age, gender and body weight were not significantly different with those who did not have pyuria. Fever duration after treatment was significantly longer in KD patients with pyuria. Erythrocyte sedimentation rate, C-reactive protein and serum concentration of alanine aminotransferase were significantly higher in patients with pyuria. Hyponatremia and coronary artery lesion were seen more often in patients with pyuria but there was no significant difference. Also serum blood urea nitrogen was significantly higher in KD patients with pyuria. Urine ß(2)-microglobulin was elevated in both patients groups and showed no difference between two groups. CONCLUSION: We found more severe inflammatory reaction in KD patients with pyuria. We also found elevation of some useful parameters like ß(2)-microglobulin that indicate renal involvement of KD through the urine test. Careful management and follow up will need for KD patients with pyuria and it is necessary in the future to study the specific parameters for renal involvement of KD.