ISSN: 2469-6706 Vol. 6 2019 Streptococcus pneumonia urinary tract infection in 3-year-old girl Daniel Lubarsky, a , 1 Daniel Garcia, b and Deepa Mukundan c aM.D. Candidate, Class of 2021, The University of Toledo Heath Science Campus, Toledo, OH, USA,bDepartment of Pediatrics, University of Toledo Health Science Campus, Toledo, OH, USA , and cDepartment of Pediatric Infectious Disease, The University of Toledo Heath Science Campus, Toledo, OH, USA Streptococcus pneumonia is a gram-positive bacterium most commonly associated with respiratory tract infections such as acute otitis media, sinusitis, and pneumonia. While a common cause of upper respiratory infections, the current Infectious Dis- eases Society of America (IDSA) guidelines on urinary tract infec- tions (UTIs) do not cite Streptococcus pneumoniae as a cause for UTIs in children. In addition, previous research associat- ing Streptococcus pneumonia with UTIs is scarce. We report the case of a three-year-old girl presenting to the emergency room with abdominal pain, vomiting, and fever. Her clinical picture was consistent with right-sided pyelonephritis. A urine analysis (UA) was conducted which showed trace leukocyte es- terase, 150 mg/dL ketones, 21-50 WBCs, and negative nitrites. A blood culture returned positive for streptococcus pneumo- niae along with right kidney hydronephrosis on ultrasound. This patient presented with a full clinical picture of pyelonephritis, fever, leukocytosis, elevated C-reactive protein (CRP) and pro- calcitonin levels. Although the urine culture did not grow any definitive single bacterium as a causative agent, due to the pre- sentation of pyelonephritis along with CVA tenderness, dysuria, and a positive blood culture, we conclude the patient was ex- hibiting urosepsis due to streptococcus pneumoniae. Upon discovering previous case reports noting S. pneumoniae as a possible agent for UTIs, we believed this bacterium is contribut- ing to the patient’s symptoms. While streptococcus pneumoniae is rarely reported as a cause of UTIs, we believe there is suffi- cient evidence that demonstrates streptococcus pneumoniae as a possible contributing cause of UTIs, especially if the patient has a coinciding septic picture. | Streptococcus pneumonia | Urinary Tract Infection | Streptococcus pneumonia is a gram positive bacterium mostcommonly associated with respiratory tract infections such as acute otitis media, sinusitis, and pneumonia (1). While a common cause of upper respiratory infections, the current Infectious Diseases Society of America (IDSA) guidelines on urinary tract infections do not cite Streptococcus pneumoniae as a cause for UTIs in children (2). The main bacterial agents associated with uncomplicated UTIs in children are Escherichia coli, Klebsiella pneumoniae, and Enter- obacter species (3). According to guidelines released by the Amer- ican Academy of Pediatrics (AAP), a UTI is defined as bacteriuria (>105 CFU/mL) of one uropathogen along with dysuria, pyuria, and urgency (4). Fever, urinary symptoms, flank pain and an abnor- mal urinalysis would appropriately raise suspicion for pyelonephri- tis (5). Previous research associating Streptococcus pneumonia with UTIs has been scarce. Miller et al. published a report on pneumo- coccosuria in children. After examining 53,499 urine samples from children, 43 (0.08%) positive for Streptococcus pnuemoniae, the re- port concluded that Streptococcus pneumoniae was more likely to be a contaminant from perineal colonization (6). Nguyen and Penn published a paper on pneumococcosuria in adults. The results were obtained from 22,744 urine samples obtained over four years show- ing the frequency of Streptococcus pneumoniae to be 38 (0.18%) of 22,744 samples (7). Dufke et al. described an 82 year old male with pyelonephritis and urosepsis found to have been caused by serotype 6A of Streptococcus pneumoniae (8). In 2011, Burckhardt and Zimmerman published a report on 3 children with history of chronic kidney disease who showed high numbers of Streptococ- cus pneumoniae in their urine (9). The following year Krishna et al. reported on 6 more cases of pneumococusuria with the isolation of Streptococcus pnuemoniae in their urine samples (10). Finally, in 2016 Burkhardt et al. conducted an analysis on 110,000 urine specimens and identified 26 urine samples (0.02%) contain Strepto- coccus pneumoniae (11). Case report Patient information. Age: 3 years old. Gender: Female. Eth- nicity: Caucasian. Related Medical Problems: None. Objective. Discuss differential of UTI in pediatric patient and Streptococcus pneumonia as a possible contributing cause of UTIs Case. A three-year-old female with no significant past medi- cal history presented to the emergency room with abdominal pain, emesis, and fever. One week prior to admission she visited a lake with her family, and one day prior the patient was at a family baby shower playing with other children of no known illnesses. Later that night the patient became fatigued, followed by emesis and com- plaints of abdominal pain. Due to the persistent abdominal pain and emesis, she was taken to an outside emergency room. In the emergency room, a complete blood count (CBC) showed 41.9 103 WBCs (88% neutrophils) and 505 103 platelets with all other values within normal limits. A comprehensive metabolic panel displayed a creatinine of 0.39 mg/dL, and an elevated alkaline phosphate of 297 units/L with other values within normal limits. A urine analysis (UA) was conducted which showed trace leukocyte esterase, 150 mg/dL ketones, 21-50 WBCs, and negative nitrites. Additionally, the patient’s CRP level was 9.81 mg/dL (reference range 0.00-1.00) A bagged urine specimen and blood cultures were also obtained at the time. The patient was given one dose of Ceftriaxone 75 mg/kg intravenously for a presumed urinary tract infection and was admit- All authors contributed to this paper. 1To whom correspondence should be sent: Daniel.Lubarsky@rockets.utoledo.edu The authors declare no conflict of interest. Submitted: 07/27/2019, published: 10/22/2019. Freely available online through the UTJMS open access option 32–34 UTJMS 2019 Vol. 6 utdc.utoledo.edu/Translation ted to the local children’s hospital for further management. Upon further questioning the patient was additionally positive for subjective fever, right ear pain, abdominal pain, vomiting, and back pain along with dysuria. On exam the patient’s abdomen was tender to palpation, primarily in the suprapubic and right costover- tebral angle (CVA) areas. Tympanic membranes appeared normal and the rest of the physical exam was unremarkable. The patient’s repeat CBC showed significant leukocytosis of 16.1 109/L (81.8% neutrophils), platelet count of 357 109/L, hemoglobin count of 10.9 g/dL, hematocrit of 32.4%, an elevated CRP of 6.7 mg/dL (reference range 0.000-0.744 mg/dL) as well as an elevated procalcitonin of 10.29 ng/mL (reference range <.05 ng/mL). A bagged urine culture specimen from the outside emergency room demonstrated >80,000 colony forming units of mixed flora suggesting contamination and the blood culture returned positive for Streptococcus pneumoniae. Based on clinical findings of fever, abdominal pain, vomiting and CVA tenderness, a complete retroperitoneal ultrasound was done to examine for pyelonephritis. The ultrasound showed trace fluid in the right renal pelvis without obstruction as well as right sided hy- dronephrosis (shown in Figure 1) with no other abnormalities. After staying afebrile for a 36-hour period, the patient was prescribed a 10-day course of Amoxicillin for urosepsis due to Streptococcus pneumoniae and discharged. Discussion This patient presented with a full clinical picture of pyelonephritis, fever, leukocytosis, elevated CRP and procalcitonin levels, and later found to be Streptococcus pneumoniae positive. Although the urine culture did not grow any definitive single bac- terium as a causative agent, due to the presentation of pyelonephri- tis with CVA tenderness, dysuria, and a positive blood culture, we conclude the patient was exhibiting urosepsis due to Streptococcus pneumoniae. Upon discovering previous case reports noting Strep- tococcus pneumoniae as a possible agent for UTIs, we believed this bacterium to be contributing to the patient’s symptoms. Though Streptococcus pneumoniae has only been a rarely reported cause of UTIs, we believe there is sufficient evidence that demonstrates Streptococcus pneumoniae to at least be considered a possible con- tributing cause of UTIs, especially if the patient has a coinciding septic picture. Figure 1. Ultrasound of right kidney demonstrating hydronephrosis (white arrows). Conclusion In summation, our goal is to present Streptococcus pneumo- niae as a potential rare cause of pediatric UTIs. In our case, we concluded our patient presented with a full clinical picture of pyelonephritis, fever, leukocytosis, elevated CRP and procalcitonin level, most likely caused due to Streptococcus pneumoniae. Physi- cians should be aware of this bacterium as contributing cause for UTIs and consider it in their differential in pediatric patients. Conflict of interest Authors declare no conflict of interest. Authors’ contributions DL wrote the manuscript, DG and DM revised the manuscript. 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