Macroscopic hematuria in a patient with leukemia: Answers
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CLINICAL QUIZ
Macroscopic hematuria in a patient with leukemia: Answers Mihriban İnözü 1 & İnci Yaman Bajin 2 & Zehra Aydın 1 & Özlem Yüksel Aksoy 1 & Altan Güneş 3 & Hüsniye Neşe Yaralı 2 & Umut Selda Bayrakçı 1 Received: 24 July 2020 / Revised: 14 August 2020 / Accepted: 7 September 2020 # IPNA 2020
Keywords Child . Acute lymphocytic leukemia . Fungal infection . Hematuria . Kidney abscess . Candida . Renal artery erosion
Answers 1. Hematuria was thought to be derived from the erosion of the branch of the left renal artery by the largest kidney abscess matching the same location. 2. Conventional angiography was performed to detect the source of bleeding (Fig. 1). 3. Angiography revealed active bleeding immediately nearby the largest kidney abscess, and selective embolization was performed. After embolization, hematuria regressed and ceased totally in 2 days. Hemoglobin level increased to 10.5 g/dL. Antifungal treatment was continued for 6 weeks. A control abdominal ultrasonography demonstrated the resolution of the kidney fungal abscesses. Two months later, abdominal ultrasound and urinalysis were totally normal.
Discussion Kidney abscess is the accumulation of infective fluid in the kidney and is quite uncommon in children. However, its This refers to the article that can be found at https://doi.org/10.1007/ s00467-020-04767-1. * Mihriban İnözü [email protected] 1
Department of Pediatric Nephrology, Ankara City Hospital, Üniversiteler Mahallesi Bilkent Caddesi, 06800 Çankaya/ Ankara, Turkey
2
Department of Pediatric Hematology, Ankara City Hospital, Ankara, Turkey
3
Department of Pediatric Radiology, Ankara City Hospital, Ankara, Turkey
morbidity is quite high, leading to severe kidney damage or even kidney loss [1, 2]. Kidney abscess may occur as a complication of urinary tract infections or hematogenous seeding [3]. The predisposing factors for kidney abscesses are vesicoureteral reflux, ureteropelvic junction obstructions, neurogenic bladder, polycystic kidney disease, nephrolithiasis, chronic systemic disease, and immunocompromised status [1]. Due to its anatomical location and proximity to surrounding tissues, kidney abscess is potentially lethal, especially in immunocompromised patients [3]. The most common microorganisms isolated in kidney abscesses are Escherichia coli and Staphylococcus aureus [1, 3–5]. In addition, anaerobic organisms and fungi, especially Candida species, might be cultured from the immunocompromised hosts [6, 7]. Candida tropicalis sepsis has become more prevalent among neutropenic patients with hematological malignancies. Kidney abscess originating from a hematogenous route during candidemia is a rare and serious complication of candida infections [8, 9]. In our patient, abscesses were multiple and bilaterally located, with the size of the largest one 3 × 2 cm. These were diagnosed as fungal abscesses due to the presence of candidemia. In small abscesses (< 3 cm) conservative management with antibiotics may safely be implemented. However, drainage is recommended for absces
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