Do not miss any of the new cases! Subscribe above to receive our newsletter! ↑↑

Do not miss the opportunity to download our app on the Google Play Store. Click here to enjoy it.

Previous

Case 340

Next


Click on the images above to zoom in

Newborn, male, with a history of oligohydramnios that required intrauterine vesicoamniotic shunt placement, with no success, evolving to an emergency cesarean delivery. He was delivery with a gestational age of 32 weeks and 3 days, and birth weight of 2,250 g, appropriate for gestational age. Apgar scores at 1 and 5 minutes were 5 and 7, respectively. He was intubated at the delivery room and transferred to the neonatal intensive care unit. He developed metabolic acidosis and electrolyte disturbances that were difficult to control, and progressive renal function decline [day 4: serum creatinine: 2.58 mg/dL (normal range 0.56-1.2 mg/dL) and BUN: 61 mg/dL (normal range 2-34 mg/dL), requiring peritoneal dialysis.

Considering the information and the images presented, which of the malformations below would best explain the clinical findings in this patient?

a) Ureteropelvic junction obstruction

25%

b) Posterior urethral valves

25%

c) Vesicoureteral reflux

25%

d) Primary megaureter

25%
   

Image analysis

Image 1: Ultrasonography of the infant’s urinary tract, B-mode linear transducer. Right kidney, longitudinal (A - blue ellipse) and transverse (B - red circle) sections, respectively, eutopic, with diffusely increased parenchymal echogenicity and moderate loss of the corticomedullary differentiation. Hydronephrosis is present, as evidenced by dilation of the renal pelvis (yellow circle and ellipse).

 


Image 2: Ultrasonography of the infant’s urinary tract, B-mode linear transducer. Left kidney, transverse (A) and longitudinal (B) sections, eutopic, with diffusely increased parenchymal echogenicity and loss of the corticomedullary differentiation (red markings). Hydronephrosis is present, as evidenced by dilation of the renal pelvis.

 


Image 3: Ultrasonography of the infant’s urinary tract, B-mode linear transducer. Pelvic cavity, transverse section. Bladder (blue circle) showing significant wall thickening and a small caliber catheter in its interior (white arrow), placed during the intrauterine procedure.


Highlights

- Posterior urethral valves (PUVs) are the main cause of chronic kidney disease secondary to urinary tract obstruction in children.
- 50% of PUVs’ cases are identified by prenatal ultrasonography.
- After birth, they are associated with early urinary tract infections, and often present as sepsis.
- The association of the following findings in fetal ultrasonography should raise suspicions for PUVs: bilateral hydronephrosis, bladder wall thickening and posterior urethral dilation and thickening, in male fetuses.
- Prenatal intervention is reserved to cases with poor intrauterine evolution, but relatively preserved renal function.

References

- Holmes N. Clinical presentation and diagnosis of posterior urethral valves. UpToDate [Internet]. Uptodate.com. 2019 [cited 3 March 2019]. Available from: https://www.uptodate.com/contents/clinicalpresentation-and-diagnosis-of-posterior-urethral-valves?search=congenital%20anomalies%20of%20the%20kidney%20and%20urinary%20tract&topicRef=6110&source =see_link

- Holmes N. Management of posterior urethral valves [Internet]. Uptodate.com. 2019 [cited 3 March 2019 ]. Available from: https://www.uptodate.com/contents/management-of-posterior-urethral-valves?search =congenital%20anomalies%20of%20the%20kidney%20and%20urinary%20tract&topicRef=6575& source=see_link

- Saldanha da Silva AA, Finotti BB, Simões e Silva AC. Válvula de Uretra Posterior - Aspectos clínicos e cirúrgicos. Revista Médica de Minas Gerais. 2018; 28. DOI: http://dx.doi.org/10.5935/2238-3182. 20180161
- Nasir AA, Ameh EA, Abdur-Rahman LO, Adeniran JO, Abraham MK. Posterior urethral valve World J Pediatr. 2011; 7 (3): 205-16.
LS Bernardes, G Aksnes, J Saada, V Masse, C Elie, Y Dumez et al. Keyhole sign: how specific is it for the diagnosis of posterior urethral valves? Ultrasound Obstet Gynecol. 2009 Oct;34(4):419-23.- Oliveira FR, Barros EG, Magalhaes JA. Biochemical profile of amniotic fluid for the assessment of fetal and renal development. Braz J Med Biol Res. 2002; 35: 215-222

Authors

Ariádna Andrade Saldanha da Silva, 6th year medical student at Universidade Federal de Minas Gerais.
E-mail: ariadna.andrade[arroba]hotmail.com

Supervisors

Ana Cristina Simões e Silva, pediatric nephrology physician. Post-doctorate in Molecular Biology. Doctor in Pediatrics. Professor at Medical School of Universidade de Minas Gerais. Leader researcher of the Pediatric Nephrology research group.
E-mail: acssilva[at]hotmail.com

Pedro Augusto Lopes Tito. Masters degree in Neuroscience from Universidade Federal de Minas Gerais. Professor at the Department of Anatomy and Imaging at Medical School of Universidade Federal de Minas Gerais.
E-mail: peralarep[at]gmail.com

Reviewers

Bernardo Finotti, William Alves, Fernando Amorim, professor José Nelson Mendes Vieira and professor Viviane Santuari Parisotto Marino.

Translated by

Rafael Antonio Teixeira Malta, 5th year medical student at Universidade Federal de Minas Gerais.
E-mail: rafaelmalta148[at]gmail.com

 

Test question

a)

25%

b)

25%

c)

25%

d)

25%

e)

25%
   

Commentics

Sorry, there is a database connection problem.

Please check back again shortly.

Bookmark and Share




Unfortunately there is no english translation available yet for this case.

Please refer to the Portuguese version instead or come back later.





Follow us:      Twitter  |    Facebook  |    Get the news  |    E-mail