U T I IN INFANCY AND CHILDHOOD


Bacilluria is a condition where large numbers of micro- organisms are found in the urine, but no pus cells. Bacilluria may present the onset or the termination of an attack of pyelitis, or it may be a distinct entity. From a practical stand- point it is safe to say that the terms “pyelitis” and pyelonephritis” cover the situation fairly well, the latter term being reserved for the more serious cases.


Merion Station, Pa. It has been emphasized by Helmholzt that about one per cent of the diseases of infancy and childhood comprise what is ordinarily termed pyelitis. Consequently, the importance of this group of infections is considerable both to the pediatricians and to the general practitioners. For this reason and because there are a number of problems worthy of emphasis in the field of urinary tract infections, it seemed worth-while to read a paper on this subject.

The term “pyelitis” is a rather broad one, and strictly speaking should be broken down into a number of separate entities: cystitis, pyelitis, pyelo-nephritis, and bacilluria. An attempt to define these different entities will be made. However, it must be admitted that clinically it is frequently difficult to distinguish between them. Several reasons account for this situation.

The findings are frequently of such a nature that from a subjective standpoint and even from an objective standpoint one has little help in telling one from the other; likewise several of these situations may co-exist.In the case of cystitis there should be present dysuria and frequent, small urinations. In smaller patients these complaints are unlikely to be very apparent. Pyelitis refers to infections seated primarily in the kidney pelvis and not in the kidney parenchyma. In pyelonephritis the kidney itself is also involved. In cases where there are marked toxemia and a high temperature elevation, one is justified in concluding that the case is one of pyelonephritis.

Bacilluria is a condition where large numbers of micro- organisms are found in the urine, but no pus cells. Bacilluria may present the onset or the termination of an attack of pyelitis, or it may be a distinct entity. From a practical stand- point it is safe to say that the terms “pyelitis” and pyelonephritis” cover the situation fairly well, the latter term being reserved for the more serious cases.

In 1837, Rayer2 first described inflammation of the urinary tract. In 1876, Huttenbrenner3 first pointed out that urinary tract infection was frequently encountered in infancy and child- hood. A period of disinterest followed Huttenbrenners work, but in 1894, Escherich4 established for all time the importance of the infections, and the place of these infections as a common cause of acute febrile disease in childhood became a prominent one.

Pyelitis and pyelonephritis are seen most frequently in the first two years of life. Females generally exhibit the infection more frequently. This is thought to be due to the short female urethra, which would facilitate an ascending type of infection. The wearing of diapers is also blamed in the part for the preponderance of these infections in early life.

Two modes of infection are generally thought to exist : the ascending and the hematogenous route. The former route had been the subject of some controversy, but it is now held that the colon infections most likely gain access to the pelvis and parenchyma of the kidney by the ascending approach. This is borne out by the infrequent discovery of colon bacilli in the blood stream. Animal experimentation has also shown that it is difficult to produce a hematogenous urinary tract infection with colon bacilli.

On the other hand the infections caused by staphylococci and streptococci are normally of hematogenous origin and can be traced quite frequently to distant foci. In the case of the staphylococci, abscesses or osteomyelitis are often the cause. It is in such cases that one occasionally sees perinephritic abscesses. Streptococci from upper respiratory infections also may lodge in the urinary tract to produce infection.

In the ascending type, it is thought that the infection travels upwards by direct extension from the bladder up the ureter. In the hematogenous type it is felt that the organisms are filtered out by the glomerulus; they are either caught in the glomerular tufts or in the intertubular capillary network. If they break into the tubular system, then infection of the lower urinary tract results.

It has been felt that under certain conditions bacteria may enter the bladder from below or the kidney from above without producing any clinical or pathological involvement. Consequently, other factors seem to be necessary; incompetent ureterocystic valves, changes in the mucous membrane due to cold probably play a part in creating an actual infection. Stasis is of great importance. Congenital anomalies of the urinary tract are the main cause of stasis in the urinary passages. Infection is particularly difficult to eradicate where stasis exists.

DIAGNOSIS.

These infections may appear in general forms. At times fever may be the only sign of importance. Prostration, pallor, vomiting, diarrhoea, distension, weight loss may all be signs of urinary tract infection. At other times the preceding infection may overshadow the urinary phase. In older children one is more likely to find local symptoms such as painful, frequent urination and bladder pain.

It has been well said by Helmholzt that these infections may show an onset, as acute and as severe as pneumonia, or as gradual as that of typhoid fever. In younger children, convulsions are encountered at times. Pain over the kidneys and costovertebral tenderness are also seen on occasion in older children, particularly where a pyelonephritis exists. The diagnostic problem of distinguishing between these infections and appendicitis must not be overlooked. A complete physical examination must always be made to check up on the possibility of an infection elsewhere.

EXAMINATION OF THE URINE.

The final diagnosis always rests on the urinary findings. It must be emphasized that in a female the specimen must be catheterized, while in a male, the foreskin must be retracted and the glans penis cleansed. The urine should always be cultured. In collecting a specimen for purposes of culturing, it is advisable to discard the first portion of the urine voided, since this comes chiefly from the urethra. If pus is found, but on ordinary media no organisms are grown, then a tuberculous infection should be suspected.

This should, then be searched for. Smears of the urine stained with Grams Method should also be carried out. This will reveal the presence of anaerobic streptococci which will not be cultured under ordinary methods. Helmholzt feels that pus in the urine should be searched for in a well-shaken specimen. The normal upper limits for males is 2-3 pus cells per low power field. In the females, the limit is 6-8 pus cells per low power field. Occasionally at the onset of a pyuria, a Haematuria is seen.

If the above precautions are not observed, there will be a tendency to include in the diagnosis of pyelitis cases of vaginitis. It is important to note that vaginitis, gonorrhoeal included, does not seem to invade the upper urinary tract.

From the clinical picture which pyelitis and pyelo-nephritis present it will frequently be difficult to make a diagnosis with- out a urine study. The case will on occasion present itself as a fever of undetermined origin.

Blood studies usually reveal some reduction in the red cell count and in the hemoglobin. There is usually a moderate leucocytosis with an increase in the polymorphonuclear count. When marked renal damage has occurred, an increase in the Blood Urea Nitrogen will be found. Exceptionally, hypertension will exist.

COURSE OF THE DISEASE.

Untreated, the infection will usually run for several weeks with acute symptoms and a septic temperature. Frequently, after the disappearance of the acute phase, there will occur a continuation of the urinary evidences of infection. This is particularly the case where congenital anomalies are present and these are producing stasis in the urinary flow.

These situations also tend towards progressive kidney destruction which may eventually produce renal insufficiency and death. At times a pyonephrosis or a pyohydronephrosis may occur and a nephrectomy may have to be performed. In pyelonephritis and pyelitis there is also a tendency to recrudescences. Neuromuscular dysfunction of the bladder and ureter also can encourage the persistence of infection.

The prognosis will depend on the nutrition of the patient, the success of the treatment and on the presence of urinary tract anomalies. In small infants, the initial infection may be so overwhelming that it can produce death rapidly. In private practice the mortality should prove negligible.

TREATMENT.

The almost successful treatment to-day consists of forcing fluids and chemotherapy. Formerly, before the advent of such drugs as sulfanilamide and sulfathiazole, the generally prevalent treatment consisted of methenamine and in the more stubborn cases either mandelic acid or the ketogenic diet. At the present time one hears less and less of these methods, because the chemotherapeutic drugs are more effective and certainly more pleasant to administer than, for instance, the ketogenic diet.

For colon bacillus infections and for most others with the exception of those infections caused by staphylococci and the streptococcus faecalis, sulfanilamide appears to be the drug of choice. These last types of infections are best treated with sulfathiazole. The object of the treatment is to obtain a sufficient concentration of the drug in the urine. Generally a concentration of 50 milli- grams per 100 cc. is an effective one. A daily dose of 0.1 gram per kilogram of body weight is adequate.

Horst A. Agerty