Hot Seat #52: 21 yo M with painless hematuria
Posted on: March 3, 2015, by : Astrid Sarvis
by Astrid Sarvis, Children’s National
with Asha Payne, Children’s National
The Case
21 yo M, pmhx of mild autism, asthma and complex partial seizures being brought in for painless hematuria and mild dysuria that started this morning. The patient reports that symptoms began with bloody urine, before experiencing dysuria with the last couple voids. Symptoms have persisted with every void. He has also noticed clots in the urine and feels like the urine “won’t come out” sometimes. No increased frequency. No fever at home. No abdominal or flank pain. He had diarrhea without vomiting a few days prior that’s since resolved. No penile trauma or urethral discharge. Denies any history of sexual activity or prior sexually transmitted infections. No bleeding from other sites. No rash.
ROS: No recent weight loss. Remainder as per HPI.
Pmhx: Constipation tx w Miralax. No prior history of UTI. Remainder per HPI.
Fmhx: Negative for renal diseases, malignancy or sickle cell disease. Otherwise noncontributory.
Pertinent Physical Exam: VS: T 38.0/ HR 111/ RR 20/ BP 126/87
General: Alert and in no distress. Pleasant. Great historian.
Skin: No rash.
Ears, nose, mouth and throat: Tympanic membranes clear. Oral mucosa moist. No pharyngeal erythema or exudate.
Gastrointestinal: Soft. Nontender. Non distended. Normal bowel sounds.
Back: No CVA tenderness.
Genitourinary: Normal genitalia for age. No penile lesions or tenderness. Circumcised. Testicles descended.
Lymphatics: No lymphadenopathy
Remainder of exam within normal limits.
You order a clean catch urinalysis which reveals RBC 5322/ WBC 338/ 2+ protein/ 3 + RBC/ neg gluc/ neg ketones/ Spec grav >1.030/ pH 6.0/ appearance turbid/ color dark red/ no epithelial cells.
Urine culture sent.
Questions for you:
Re-examination
Pending labs returned:
CBC: WBC 18.7/ Hb 14.9/ Hct 43.5/ Plt 272 Diff: 84.2 segs/ 10.7 lymph/ 4.5 mono
Renal panel: Na 138/ K 3.7/ Cl 101/ CO2 23/ Gluc 123/ BUN 11/ Creat 1.0/ Ca 9.7/ Alb 4.1/ and Phos 3.2
COAGS: PT 16.5/ PTT 35.2/ INR 1.3. 138
Prot:creat ratio slightly elevated, not nephrotic range.
BPs range 120-125/80s
Low grade fever persists several hours after Tylenol, but the patient continues to be very well appearing and hemodynamically stable.
US reveals a 2cmx2cm hypoechoic lesion in the R kidney possibly c/w simple cyst vs calyceal diverticulum, and a urachal remnant, no hydronephrosis, no US-visible stone.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
With a wonderful historian such as this, it really helps to focus on the unusual signs/ symptoms. Straining to void is not a common issue in the ED and to me at least implies a strong likelihood of a urological problem (likely obstruction) and not a renal issue. The fever, dysuria, and UA suggest a UTI, although I doubt this is the only or underlying problem. Tests I would ideally like in the ED would be review of the urine by nephrology (if daytime and possible), post-void bladder US to assess for retention, complete neuro exam including rectal tone, and consult urology.
I think the case also raises an issue I often struggle with, namely, if the diagnosis still remains unclear do you admit or discharge this patient? Obviously it is a case-by-case issue, however the theme of clinically stable, needing close f/u from 1 or more sub-specialties, and unknown diagnosis seems to describe several cases I’ve had where the disposition is difficult to decide on.
Specific diagnoses? Posterior urethral valves or ureterocele perhaps?
So Mordechai blew me away on the last one of these when i went through a diatribe about localizing a neuro lesion and missed the microcytic anemia and diagnosis of VOC…..kudos Mordechai!
But in this case, maybe i’m missing something?!? I’m more concerned about gross hematuria with clots in the absence of dysuria or wbc because it can signify a bladder or urethral tumor. But with pain, fever and wbc in the urine, and in the absence of hypertension, I’m not sure why this isn’t an uncomplicated hemorrhagic cystitis?
I would’ve treated this as a presumed infection and never sent blood and would not have seen the indication to do an US. And i don’t think the questionable renal mass or minimally elevated PT changes much here. Clots and gross hematuria without casts indicates a lower GU source so that should have nothing to do with the insignificant mass in the kidneys that you should’ve never looked for anyways. if the urine culture is negative, there are several viral infections that are known to cause hemorrhagic cystitis. Adenovirus is classic.
Do fewer tests. Differentiate lower and upper GU bleeding.
Taking it from the top, here are my thoughts:
-Trauma- Being an EM physician, trauma is frequently on the top of my list of diagnoses. In this particular case, I wonder if he had a new type or atypical seizure than he normally has. (Did he sustain renal/GU trauma during one of these episodes?)
-Medications- the case does not mention if he is taking any regular medications which might contribute to his current presentation. While off hand, I don’t think any of the frequently used seizure medications would cause this presentation, but the combination of the prescribed and non-prescribed (drugs), may be relevant.
-Vitals-he is tachycardic and (technically) hypertensive. The HR of 111 seems more than could be attributed to his low grade fever. Further, the clinical history does not suggest dehydration. That said, I’d make there was a repeat set of vitals. It’s always important to recognize that vital signs may contribute more to the story than the patient may suggest. While in this case, it does not sound like the bleeding has been copious, but in another situation, the first glance of a HR of 111 could suggest a significant degree of anemia.
-PE- In evaluating a patient with suspected renal disease, examining for edema, fluid overload (gallop), and/or crackles is critical. The case states “remainder of exam is within normal limits” but in this case, as the attending, I would definitely confirm this for myself. Be selective with what others describe in the physical. Never be shy about confirmation. Also, I would try to get an estimation of any recent weight gain.
-DDX/Management-In terms of management, I would have clarified how the course of the ureters and bladder looked on the US. While this is not as detailed as a VCUG, it’s always good not to make assumptions that “they were fine since radiology didn’t mention them.” To Mordechai’s point, I think that we all struggle with the dispo. There are times where I want to admit just so the workup can be more expeditiously, but we have to remember our resources here: do they have a good PMD that can continue the w/u? Are they medically stable and without a strong likelihood of deterioration? Have the appropriate subspecialists been made aware of the patient and can they facilitate additional management as an oupt?
Very cool case. For this kid (21 yo? WHC…)
UA: Looks non-glomerular with a presumptive working dx of UTI (viral or bacterial; nitrite result pending?) and empiric treatment with 3rd gen ceph after cx sent off.
U/s: good to get mainly to look for tumors and some stones; but he’s not giving a great pain hx for a stone or nutcracker syndrome, so I’m less worried about missing those. Tumor (renal, ureteral, bladder) is not very sensitive with u/s to dx it and he needs a urologist to cystocopy (+/- bx prn) if his sx and UA don’t normalize in 1 week. If he’s still sx after a week, then he likely needs that urologist and more imaging of his abdomen.
Other ddx: renal calculi not seen on u/s, blunt trauma, schisto if a traveler, self-urethral injury from insertion of who knows what.
I would also like to see d/c vitals of HR<90 (you said "hemodynamically stable" and a tachycardic kid should not be so I assume this is fine) and BP 3 days, urinary retention from a clot, no u/o x 12 hours, ill/worsening, etc.