Hot Seat Case #123: 5 year old male with red urine
Posted on: January 9, 2019, by : Hilary Ong
Hilary Ong, MD Children’s National Medical Center
with Shilpa Patel, MD Children’s National Medical Center
HPI:
5 year old uncircumcised male with speech delay, who presents with red urine for 2 days. 2 days prior he developed acute onset of red discoloration of urine. Since then each time he urinates it is red in color and fills the toilet bowl. Unclear if red urine starts at onset of urination, throughout urination or at the end of urination. It is painful at the tip of his penis while he urinates, but denies any flank pain with radiation. He went to his pediatrician the day prior to arrival, and was told that the tip of his penis was red with a “bump” after retraction of his foreskin. Per mother’s report, urinalysis was negative. At that time, and he was sent home with mupirocin ointment.
The boy denies any trauma, urinary incontinence, urgency or frequency. He has not had any recent antibiotics or ibuprofen. He has not had any red color foods such as beets. Mother denies any recent URI or strep throat infection.
ROS:
Constitutional symptoms: Denies fever, denies chills, denies fatigue
Skin symptoms: Denies rash
ENMT symptoms: Denies recent sore throat, nasal congestion
Respiratory symptoms: Denies cough, denies shortness of breath
Cardiovascular symptoms: Denies chest pain
Gastrointestinal symptoms: Denies abdominal pain, no vomiting, no diarrhea, no constipation
Genitourinary symptoms: Dysuria, hematuria, no discharge
Musculoskeletal symptoms: Denies muscle pain
Neurologic symptoms: Denies headache, denies dizziness, denies weakness
PMH: Speech delay; Asthma
Medications: Mupirocin ointment, albuterol PRN
Social Hx: Lives with parents and older brother
PE: T 37.0 HR 90 RR24 BP 105/71 SaO2 100% on RA
General: Alert. well appearing.
Skin: Warm. dry. intact. no pallor. no rash. No signs of facial or peripheral edema
Neck: No lymphadenopathy.
Eye: Normal conjunctiva, PERLA, EOMI, no scleral icterus
Ears, nose, mouth and throat: Tympanic membranes clear. Oral mucosa moist. No pharyngeal erythema or exudate.
Cardiovascular: No murmur. No gallop. Regular rate and rhythm. 2+ radial pulses.
Respiratory: Lungs CTAB, normal WOB, symmetric chest wall expansion
Gastrointestinal: Soft. Normal bowel sounds. Non distended abdomen. No hepatosplenomegaly.
Genitourinary: Uncircumcised male, easily retractable foreskin, normal genitalia for male, no evidence of aforementioned redness or lesion on tip of penis, meatus is pink without blood or lesions, no CVA or suprapubic tenderness.
Musculoskeletal: Moves all extremities
Neurologic: Alert, non-focal neurologic examination
Repeat urinalysis in ED showed:
Glucose negative Spec Grav 1.024
Total Protein 3+ RBC 6971
Urobilinogen Normal WBC 209
PH 6.0 Epithelial cells None
Blood 3+ WBC clumps many
Ketones Negative Bacteria None
Nitrite Negative
LE 1+
Appearance Cloudy
Vital signs and PE are unchanged.
Labs/Imaging as shown below:
CBC normal, CMP normal, Phos 5.5
C3/C4, ASO tites, Urine culture, and Urine protein/creatinine pending
US: Diffusely thickened bladder wall with mild increased interval vascularity. Normal kidneys bilaterally. No hydronephrosis. No nephrolithiasis.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
Hematuria with dysuria argues for a non-glomerular cause of the hematuria — typically urethral, bladder or ureteral. Obtaining complement levels and ASO titers looking for common glomerular causes of isolated hematuria would probably not be the most cost-conscious studies to obtain. Hematuria, pyuria, and dysuria together necessitates an ultrasound — as that’s likely where the “money” is!
Agree with above, though the proteinuria catches my attention and ‘dysuria’ is often overdescribed by younger boys. With 3+ protein, the exam appropriately excluded peripheral edema, and with the hematuria, I review the BP mindfully.
With hematuria, I use history and labs to help with my ddx of infection, trauma, stones, tumor, nephritis/nephropathy, and bleeding disorders. The imaging is useful to evaluate the kidney size (long-standing disease resulting in reduced size and change in architecture), to identify if there is a mass, and to look for indirect signs of stones.
The child is well-appearing, with a normal BP. He can be followed as an outpatient pending the labs, with antibiotics if the follow-up is not certain, or without if the PMD can see him in 1-2 days to check his BP.