Case presented was an 18-year-old female that had recently given birth (January) presenting with abdominal pain, nausea, vomiting, diarrhea, backache. Laboratory findings pointed to pyelonephritis but also showed hypokalemia. In trying to relate that finding to the infection, a search was done in Medline.

Database: Ovid MEDLINE(R) 1950 to Present with Daily Update Search Strategy:

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1     Pyelonephritis/ (12397)

2     Hypokalemia/ (6459)

3     1 and 2 (37)

4     limit 3 to english language (14)

Of the 14 articles retrieved one discussed this finding in very young infants  who were in very poor health and dehydrated. The only other relevant article was from 1963, from the Annals of Internal Medicine entitled “The relationship of chronic pyelonephritis to chronic potassium deficiency.”  A follow-up search in PubMed (pyelonephritis and (hypokalemia or potassium)) retrieved an even older case report article from 1956,  from the British Medical Journal entitled “Potassium-losing pyelonephritis.” Their conclusion: “Thus we postulate that only a renal lesion could explain the clinical and laboratory findings in this case. This lesion may either have been present before the attacks of pyelonephritis or could possibly have developed as a result of it.” By the magic of citing forward this led to a 1969 article that followed up on the topic.

A quick look into some of our e-Textbooks did not offer too much help, but a discussion in Harrison’s Principles of Internal Medicine  did address the question of continued fever in the patient:

“The manifestations of acute pyelonephritis usually respond to appropriate therapy within 48-72 h. However, despite the absence of symptoms, bacteriuria or pyuria may persist. In severe pyelonephritis, fever subsides more slowly and may not disappear for several days, even after appropriate antibiotic treatment has been instituted. Persistence of fever or of symptoms and signs beyond 72 h suggests the need for urologic imaging.”

Finally, the discussion of the possibility of this patient having retained placenta causing an infection led to the question of how long post partum should this be considered a concern.  This was a bit elusive, but a search of the National Guideline Clearinghouse, an excellent web site for evidence-based clinical guidelines, turned up this somewhat related statement in a guideline on postpartum hemorrhage:

A 2-month old presented with fever, upper respiratory symptoms and poor feeding. The discussion pointed out the importance of considering a more serious bacterial infection occuring along with a viral infection. To investigate what the current guidelines and considerations are the following general search was performed in Ovid Medline:

1     exp Infant/ (801916)

2     Respiratory Syncytial Virus Infections/ (3449)

3     Bacterial Infections/ (52698)

4     1 and 2 and 3 (26)

I used Infant (exploded to include infant, newborn) as a subject term. You could also combine RSV and bacterial infections and then use the age limit of all infant to restrict your results. In this case, the same 26 articles would be retrieved, but occasionally it may be useful to do the search both ways to be sure you do not miss anything. The human side of indexing can create discrepancies, and this is one way to double-check your strategy.

The results proved interesting, in that there seems to be some varying opinions on how to manage these infants. This 2004 article, Risk of  serious bacterial infection in young febrile infants with respiratory syncytial virus infections in Pediatrics by Levine et.al. concludes that “febrile infants who are < or =60 days of age and have RSV infections are at significantly lower risk of SBI than febrile infants without RSV infection. Nevertheless, the rate of SBIs, particularly as a result of UTI, remains appreciable in febrile RSV-positive infants.”

Also raised in the discussion was the possibility of hyperbilirubinemia occuring in newborns taking ceftriaxone. I retrieved only one  useful article (this time in PubMed, searching ceftriaxone and infants and hyperbilirubinema. Only the abstract for this article is available.

Safety of ceftriaxone sodium at extremes of age

Conclusion: “Ceftriaxone should be avoided or significantly minimized in neonates (especially those treated concomitantly with intravenous calcium solutions and those with hyperbilirubinemia).”

Lastly, the question arose of guidelines for treatment of UTI in infants. A search of the National Guideline Clearinghouse (www.guideline.gov) retrieved Evidence-based clinical practice guideline for medical management of bronchiolitis in infants less than 1 year of age presenting with a first time episode from Cinncinati Children’s Hospital.

A 20-month-old presented with fever, rash in the groin and trunk, swelling of hands and feet, and bilateral conjunctivitis. A diagnosis was made of Kawasaki Disease. The differential discussion raised the possibility of Staphylococcal Scalded Skin Syndrome. I did the following quick search in Ovid Medline to see if any articles discussed both problems:
1 Mucocutaneous Lymph Node Syndrome/ (3692)
2 Staphylococcal Scalded Skin Syndrome/ (241)
3 1 and 2 (3)
4 from 3 keep 1-3 (3)

Note that the official MeSH term for Kawasaki Disease is “mucocutaneous Lymph Node Syndrome. Of the 3 articles retrieved, a nice differential diagnosis discussion on fever and rash appeared in Pediatric Annals 36:1, 30-38, 2007.  Fever and Rash in a Child: When to Worry?

Excellent images of five key symptoms of Kawasaki Disease are available from the Children’s Hospital, Boston.

The case presented was a 6-year-old female admitted with painful red bumps in her mouth. Tongue was swollen and she had thick white plaque-like lesions in her mouth. A culture grew candida and a diagnosis of Crohn’s disease was made after endoscopy. Patient did not present with gastrointestinal symptoms.
Clinical question: Do studies show a relationship between candida and Crohn’s in a young patient?
The following general search was performed in Ovid Medline:
1 Crohn Disease/ (24359)
2 exp candida/ (28900)
3 1 and 2 (24)
4 exp Mouth/ (200349)
5 tongue/ (12614)
6 4 or 5 (212963)
7 3 and 6 (3)

Search Strategy: Using the MeSH (medical subject headings), I combined Crohn Disease (notice the official term is singular) with candida. I also “exploded” candida to include all of the more specific organisms. You can always see what exploding will include by clicking on the link for the term you are searching in Ovid. Exploding allows your search to cast a wider net. This combination only retrieved 24 articles. This review article from Current Opinion in Gastroenterology looked like it contained a good discussion:

Pathogenic agents in inflammatory bowel diseases

Adding the terms ‘mouth’ or tongue’ to our search narrowed the results down to just 3 articles, but none looked helpful. However, another study from the original 24 retrieved that focused on the immunological basis for developing candida in Crohn’s disease patients looked interesting:

Candida albicans Colonization and ASCA in Familial Crohn ’ s Disease