Macroscopic hematuria in a patient with leukemia: Questions
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CLINICAL QUIZ
Macroscopic hematuria in a patient with leukemia: Questions 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 . Kidney abscess . Hematuria
Case A 2.5-year-old girl was admitted to our hospital with fever (38.8 °C), fatigue, and paleness. There were no known diseases in this patient or family history. She was the third child of first-degree cousin parents. Physical examination revealed fever, paleness, petechial rash, and hepatosplenomegaly. Clinical findings and laboratory results were compatible with pre-B acute lymphocytic leukemia (ALL). She had had induction therapy with ALL-IC-Berlin Frankfurt Münster (BFM)-2000 treatment protocol consisting of prednisolone, vincristine, daunorubicin, L-asparaginase, and methotrexate. Broadspectrum antibiotics had been administered since the first day of hospitalization for neutropenic fever. Amphotericin B was added empirically on the 19th day of hospitalization for persistent fever, rash, and increased acute phase reactants to treat suspected fungal infection. However, her clinical condition worsened, and chemotherapy had to be ceased after 3 weeks due to severe The answers to these questions can be found at https://doi.org/10.1007/ s00467-020-04778-y. * 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
sepsis. Thorax CT and abdominal ultrasonography revealed hypoechoic lesions suggesting fungal infection of the lung, spleen, and bilateral kidneys. Skin and blood cultures yielded Candida tropicalis. Amphotericin B was replaced with fluconazole in accordance with susceptibility tests on the 25th day of hospitalization. Macroscopic hematuria started 4 days later after switch of antifungal medication. Laboratory data at the time of gross hematuria onset were as follows: white blood cells (WBCs) 2600/mm3, absolute neutrophil count 450/mm3, hemoglobin 7.2 g/dL, thrombocytes 47.000/mm3, urea 33 mg/dL, serum creatinine 0.3 mg/dL, sodium 136 mmol/L, potassium 3.9 mmol/L, and serum albumin 3.9 g/dL. Urinalysis revealed a moderate increase in specific gravity (1.029), significant hematuria (3+), and trace proteinuria. Urine sediment examination showed eumorphic erythrocytes. Spot urine calcium to creatinine ratio, spot urine uric acid to creatinine ratio, and urine culture were normal. Blood and urine PCR tests for adenovirus and BK virus were negative. Repeat sonography revealed mild enlargement of both kidneys and bilateral multiple hypoechoic masses; a possible diagnosis of bilateral fungal abscess was detected, and bladder hematoma was also observed. Renal art
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