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Case 177


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Female patient, 1 year and 8 months old, attends the pediatrician’s office with her mother, reporting high fever (39 ° C) for the past five days associated with appetite loss, without other complaints. On physical examination, the child was tearful, irritable, with axillary temperature of 38,7ºC, HR: 130 bpm, RR: 35 bpm, with no change in the rest of the examination. Was performed urinalysis, complete blood count and CRP whith the following results. Urinalysis: density 1015; pH 5.5; positive nitrite; sedimentoscopy with fields full of pyocysts and rare red blood cells; no cylinders were seen. Culture of the urine was began ; CBC: Red blood cell count: 4.08 million; Hemoglobin: 11.4; hematocrit: 33.6; Platelet count: 314,000; White blood cell count: 13,800; Banded neutrophils: 0; Mature neutrophils: 59.6%; Eosinophils: 0.1%; Monocytes: 5.2%; Lymphocytes: 34.9%; CRP: 51 Result Gram and urine culture: Gram: many gram negative rods Culture:> 100,000 CFU; identified germ: E coli multidrug sensitive. Later ultrasound of the urinary tract was requested, whose images are attached.

Based on the clinical picture and the data obtained, what is the best workup?

a) Hospitalization; initial intravenous antibiotic treatment; ultrasound of the urinary tract; voiding cystourethrography.


b) Intramuscular antibiotic therapy until resolution of fever; static renal scintigraphy


c) Antipyretic and symptomatic; wait for result of urine culture and then ultrasound of the urinary tract


d) Outpatient treatment; antibiotics mouth with following prophylaxis; voiding cystourethrography


Image analysis

Image 1: Kidneys with normal appearance; parenchyma with normal echogenicity; preserved corticomedullary differentiation; absence of hydronephrosis.

Volume right kidney (RK): 25cm³ (Normal value: 19-44); Volume left kidney (LK): 37cm³ (Normal value: 20-46)

Thickness of the parenchyma: RK: 5.9 to 17.1; LK: 7.3 to 18.6

Measures of the anteroposterior diameters of the renal pelvis (AP): RK: 5.0mm; LK: 4.0mm (Normal value: up to 5mm)


Image 2: Width of the proximal and distal ureters: (Normal value: up to 4mm)

Right proximal ureter: 3.5mm; distal: 5.6 mm (white arrow)

Left proximal ureter: 3.0mm; distal: 3.3mm (white arrow)

Bladder wall thickness (Normal value: up to 5mm with empty bladder; up to 3mm with full bladder): 3.1 to 3.7 mm. Maximum volume of 79ml pre-urination and minimum volume of 2.0ml, post-urination.

Conclusion: Right kidney with minimal reduction of the parenchyma and overall renal volume corresponding to 68% of the LK’s volume; mild dilatation of the distal ureter. This data suggests a mild inhibition of renal growth in the right, associated with mild dilatation of the ureter, so that there is a possibility of vesicoureteral reflux to the right.


- A urinary tract infection is a common condition in childhood.

- The imaging workup is indicated in children in the first confirmed episode of urinary tract infection, varying according to age and clinical condition.

- The vesicoureteral reflux may be associated with recurrent urinary tract infection, being suspected due to alterations in the ultrasound, such as dilatation of the ureters, collecting system and papilla, as well as reduced renal volume.

- The diagnosis of vesicoureteral reflux is confirmed by the voiding cystourethrography. It can also be diagnosed by direct radionuclide cystography.

- The treatment of vesicoureteral reflux is conservative: antibiotic prophylaxis, bladder training, clinical monitoring and periodic imaging workup (ultrasound and static scintigraphy).


- Mattoo TK, Saadeh AS. Managing urinary tract infections. Pediatr Nephrol 2011, 26:1967–1976.

- Shaikh N, Hoberman A; Urinary tract infections in infants and children older than one month: Acute management, imaging, and prognosis. In UpTodate, 2014. .

- Sociedade Brasileira de Pediatria; Ancona LF; Campos JD; Aguiar, MJB; Silva, JMP; LIMA, EM. Tratado de pediatria. Barueri: Manole, 2007.


Janaína Chaves Lima, 6th year medical student at UFMG. Email: janaina-chaves[at]

Luanna da Silva Monteiro, 6th year medical student at UFMG. Email: luannasmonteiro[at]


José Maria Penido Silva, professor of the Department of Pediatrics of UFMG’s School of Medicine.

Mônica Maria de Almeida Vasconcelos, professor of the Department of Pediatrics of UFMG’s School of Medicine.

Translated by

Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG. Email: barbara.bragaglia[at]


Translated by

Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG. Email: Barbara.bragaglia[at]


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