Possible pyelonephritis?

Re: Possible pyelonephritis?

Clive Ansell — Fri, 28 Oct 2011 13:35:01 GMT

This reminds me of a case I recently dealt with.

An elderly Irish Setter had pu/pd and isothenuria over several months along with recurrent anal gland abscesses. many courses of antibiotics were given which would clear up the abscessation, but it would recur fairly quickly. it was noted that while the dog was on antibiotics for its AG's the pu/pd reduced.

Routine bloods showed a slight neutrophilia, but otherwise unremarkable. an ACTH stim test and urinary cortisol ruled out Cushings or Addisons. Urinalysis of a cystocentesis sample showed only a isothenuria, and no growth on repeated C&S. water deprivation test showed ability to concentrate urine. abdominal radiography and ultrasonography were unremarkable.

An AG swab grew a Proteus sp. sensitive to amox/clav but little else. It is now on an 8 weeks course primarily for its AG's, but pu/pd seems to be resolving too, so I am wondering whether there is/was a secondary or separate pyelonephritis going on too. Investigation has ruled out other causes for the pu/pd. I had ruled out renal infection given that urine C&S was repeatedly negative, but learnt at a recent cpd that it can be the case sometimes.

Re: Possible pyelonephritis?

Richard Fox — Fri, 28 Oct 2011 12:52:44 GMT

One other differential is cystitis on top of CRF?

Re: Possible pyelonephritis?

Christopher Saul — Thu, 27 Oct 2011 23:42:00 GMT

[quote user="Thomas Ward"]I've read that now we have PUPD the azotaemia is less likely to resolve as the kidneys are likely to be irreversably damaged - would you agree?[/quote]

Not sure you can make that assertion. I think you have to 'suck it and see'... I certainly wouldn't promise to the owners that you will get a return to normality, though it is possible. Whatever antibitoic you finally end up on, be sure to continue treatment for at least 4 weeks, then re-culture a few days later........

Re: Possible pyelonephritis?

Tom Ward — Thu, 27 Oct 2011 23:35:47 GMT

Thank you all for your quick replies, it's much appreciated! Sorry for my poor signalment - she's female neutered. The SG is before any fluids, so is pretty suggestive of loss of concentrating ability I would suspect. I did get a sediment exam performed - I'll post everything here. I suspected the amylase could be high 2ry to renal failure, but the BA was a little odd.

MICROBIOLOGY
Urine protein              0.4         g/l
Urine creatinine           5.57        mmol/l
Urine protein/creatinine   0.63        gm/gm          (   <1.0    )
Culture & Sensitivity
Culture only               No bacterial growth cultured after 24 hrs incubation.
                           Nevertheless, the plates will be incubated for a
                           further 24 hrs and a report sent only if there is a
                           change in the above result.
Centrifuged Urine Deposi   Many wbcs, some rbcs, some squamous cells, very
                           occasional hyaline cast, occasional transitional
                           epithelial cell, moderate level of amorphous debris, no
                           crystals seen.
Urine protein (pad)        Trace       g/L
Glucose                    Negative    mmol/L
Ketones                    Negative
pH (meter)                 5.30
Specific gravity           1.015
Blood                      ++          eryth/ul
Description                Pale yellow and clear

BIOCHEMISTRY
Total Protein              71          g/l            ( 54 - 75 )
Albumin                    29          g/l            ( 25 - 37 )
Globulin                   42          g/l            ( 25 - 52 )
Albumin/Globulin ratio     0.7         ratio
Urea                     * 13.1        mmol/l    High ( 3.3 - 8.33)
Creatinine               * 216         umol/l    High ( 35 - 140 )
Sodium                     148         mmol/l         ( 140 - 155 )
Potassium                  4.8         mmol/l         ( 3.5 - 5.5 )
Na/K Ratio                 30.8        ratio          ( 25 - 35 )
Calcium                    2.58        mmol/l         (2.30 - 3.00)
Phosphorus                 1.70        mmol/l         ( 0.7 - 1.8 )
ALP                      * 200         iu/l      High (    <108   )
ALT                        20          iu/l           (    <55    )
GGT                        8           iu/l           (    <10    )
Bile Acids               * 28.4        umol/l    High (    <10    )
Cholesterol                4.2         mmol/l         ( 3.1 - 10.1)
Triglycerides              0.55        mmol/l         (0.29 - 3.88)
Total Bilirubin            0           umol/l         (    <3.4   )
Amylase                  * 2034        iu/l      High (   <1650   )
Lipase                     40          iu/l           (    <180   )
Creatinine Kinase        * 270         iu/l      High (    <90    )
Glucose                    5.0         mmol/l         (3.05 - 6.1 )

                          HAEMATOLOGY
Haemoglobin              * 11.4        g/l       Low (12.0 - 18.0)
Red Blood Cells          * 5.48        x10^12/l Low ( 5.5 - 8.5 )
PCV                      * 0.305       ratio     Low (0.37 - 0.55)
MCHC                       37.4        g/dl           (32.0 - 39.0)
MCH                        20.8        pg             (19.0 - 26.0)
MCV                      * 55.7        fl        Low ( 60 - 77 )
Platelets                * 565         x10^9/l   High ( 150 - 500 )
White Blood Cells        * 25.1        x10^9/l   High ( 6.0 - 15.0)
Neutrophils              * 79% 19.83 x10^9/l   High (3.00 - 11.5)
Neutrophils (Band)       * 8%   2.01 x10^9/l   High (0.00 - 0.30)
Lymphocytes                 8%   2.01 x10^9/l        (1.00 - 5.00)
Monocytes                * 5%   1.26 x10^9/l   High (0.00 - 0.35)
Haematologists Comment     Some deterioration of sample may have interfered with
                           interpretation of cell morphology.
                           Wbcs - possibly occasional PMN showed signs of toxicity,
                           with the presence of Dohle bodies.
                           Rbcs - anisocytosis +, polychromasia +. Some
                           echinocytes, occasional Heinz body, acanthocyte and
                           blister cell seen.
                           Platelets - some large platelets seen.

That's very interesting abut the drop of formalin for cellular preservation - I don't think I've ever heard that before! I'll book her in for u/s as soon as possible. I've read that now we have PUPD the azotaemia is less likely to resolve as the kidneys are likely to be irreversably damaged - would you agree?

Thanks again!

Re: Possible pyelonephritis?

Christopher Saul — Thu, 27 Oct 2011 23:24:28 GMT

Hi Tom! Is the dog female? could you post the pathologist's comment on the urinalysis and and the remainder of the bloods?

[quote user="Thomas Ward"]Treatment for CRF was begun, and a urine sample requested.[/quote] Was the urine sample obtained before any fluid treatment was started, i.e. is the SpG truely representative? If the urine SpG of 1.014 IS representative, then you have demonstrated functional renal impairment.

Which urine pannel did you request from the lab? I think that you might get useful information from a urine cytology; by this I mean you need to send some urine in a plain blood tube with a drop of formalin for celular preservation (toghether with the plain and boric)

To answer your questions: - Yes it is possible to get a false negative urine culture... the bacteria can lyse in dilute urine, especially if has been sitting around for a while.Given your results so far; a neutrophilia with left shift, and pyuria, I would agree that this is suspicious for pyelonephritis.

I would ideally try to get another urine sample first before starting antibtiotics ( preferably a cystocentesis sample). I would however start antibiotic therapy as soon as I had obtained the sample, rather than waiting for culture results. I would start on a penicillin as these are well concentrated in urine as my first empirical choice pending the sensitivity.

I think an ultrasound is the way forward; you can get the cysto sample under ultrasound guidance, and inspect the urinary tract closely. Dilation of the renal pelvises would support the diagnosis of pyelonephritis.

A note of caution: those bile acids are worth looking at. what were the other liver values? I would certainly do a post prandial bile acids on this dog, as well as ultrasound the liver.

Oh and this is a cocker; might be worth doing a cPLI too, they are very much over represented re pancreatitis ( just thinking about the abdo pain)

Hope this helps

Chris

Re: Possible pyelonephritis?

Evelyn Barbour-Hill — Thu, 27 Oct 2011 23:24:16 GMT

[quote user="Utlendigur"]Was the haematuria significant enough to account for the anaemia?[/quote]

I am without question on dangerous ground now: but I wouldn't say that there was an anaemia.

Well. All right. It's a mild anaemia.

Can we have a haematologist along here please?

[quote user="Utlendigur"]usually expected proteinuria and bacteria with pyelonephritis.[/quote]

A sediment examination would be very useful.

Re: Possible pyelonephritis?

Utlendigur — Thu, 27 Oct 2011 23:18:01 GMT

I've lost count of the number of cocker spaniels we've had with pancreatitis - which could mimic lumbar pain, and cause high amylase, BA, ALP and neutrophilia and maybe pre-renal azotaemia (but not sure why the SG would be low in that case) - may be worth spec cPLi. Was the haematuria significant enough to account for the anaemia? Any melaena? Male or female dog? eg could the haematuria and WBCs be coming from elsewhere such as prostate or season I'd have usually expected proteinuria and bacteria with pyelonephritis. Just very random thoughts..

Re: Possible pyelonephritis?

Laurence Webb — Thu, 27 Oct 2011 23:16:46 GMT

I seem to recall being told my a specialist that, although pencillins are concentrated in the urine, fluroquinolones get into the kidney parenchyma better, so amoxy/clav is great for lower urinary tract infections but a fluroquinolone is better for kidney infections. Giving it both would of course cover both options.

You can get pyelonephritis with sterile urine, especially a voided one of quetionable heritage. Ultrasound sounds a good idea. An intravenous urogram may help if you haven't got access to ultrasound but obviously involves some risk to renal function.

Re: Possible pyelonephritis?

Andrew Kent — Thu, 27 Oct 2011 23:15:00 GMT

Negative culture does not rule out pyelonephritis. If possible may be worth a cysto sample in plain and boric acid for culture if you want another go. Otherwise can start on antibiotic and reassess urine after 2 weeks. If improvement then continue for 6 weeks or so. Andy

Re: Possible pyelonephritis?

Gillian Mostyn — Thu, 27 Oct 2011 23:13:28 GMT

[quote user="Thomas Ward"]Would people normally treat with antibacterials (difficult without C&S) straight away[/quote]

yes - definately.

Not sure why you are worried about treating with antibacterials in this case - high WBC count with renal problems pretty much demands it, doesn't it? Surely you routinely have more cases where you treat suspected infections without C+S that you do with it?

Re: Possible pyelonephritis?

Evelyn Barbour-Hill — Thu, 27 Oct 2011 23:09:59 GMT

People with huge expertise will be along shortly, but I'd just say that it is horribly easy to mistake kidney pain for lumbar musculoskeletal pain, and yes, it can apparently go away. I would have pyelonephritis as you do, very high on the list. I'd think that an antibiotic right now would be very much justified. Clavulanate-amoxycillin would do fine to start with, wouldn't it?

PS Did you get a urine sediment examined? ( not criticising, just asking!) Casts could be quite informative.