Hilary Ong, MD Children’s National Medical Center

Case: 5 yo male with speech delay presented with 2 days of acute onset red urine with potential dysuria. No associated abdominal pain, nausea, or emesis. Workup at the PMD was unremarkable and treated as potential irritation with mupirocin. Examination in the ED was unremarkable, however, UA contradicts results of previous one.

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Discussion:

This is a great case to remind us that red urine does not always mean blood (although in this case it does!). Red urine can be from hemoglobin, myoglobin, food, or antibiotics (dang you cefdinir). With this in mind, the urinalysis is a great place to start despite having a reportedly “normal” UA at the pediatricians office. The UA here revealed true hematuria so now the differential can be directed toward renal issues.

There was a clear split in the group between who would go down simply the UTI route of workup and others who would push the envelope and go down the glomerulonephritis route. Ultimately the workup was less suspicious for a nephritic process and the renal ultrasound was more concerning for cystitis. The latter poll questions really showed the variation in risk tolerance not only between fellows and attendings, but also within their groups.

Denouement:

Both urology and nephrology were consulted from the ED. Urology felt this case was consistent with acute viral cystitis and recommended discharge home without antibiotics and follow up in 2-3 weeks. Nephrology concurred and advised as needed nephrology follow up, given normal creatinine and normal blood pressure.  Based on degree of leukocyturia and hematuria, the patient was discharged home with a course of antibiotics  for uncomplicated cystitis.

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