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Peptostreptococcus Asaccharolyticus Renal Abscess: a Rare Cause of Fever of Unknown Origin

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Peptostreptococcus Asaccharolyticus Renal Abscess: a Rare Cause of Fever of Unknown Origin Peptostreptococcus asaccharolyticus Renal Abscess: A Rare Cause of Fever of Unknown Origin Veronica A. Mas Casullo, MD*; Edward Bottone, PhD‡; and Betsy C. Herold, MD* ABSTRACT. Renal abscess is uncommon in pediatrics patients cared for on the pediatric services from December 1988 to and is rarely a cause of fever of unknown origin. We December 1998. The medical charts were reviewed for clinical recently cared for a patient who presented with a 3-week presentation, presence of underlying diseases, diagnostic proce- history of fever. An indium scan ultimately led to the dures, microbiology, surgical procedures, antibiotic therapy, and outcome. diagnosis of a renal abscess. Aspiration yielded Pep- tostreptococcus asaccharolyticus. This unusual case prompted a review of the clinical and microbiologic fea- RESULTS tures of renal abscess in pediatric patients at our hospital Index Case over the past 10 years. Seven additional patients with a discharge diagnosis of renal abscess were identified. An 11-year-old white boy with a history of coarc- Only 2 of the patients had identifiable risk factors (dia- tation of the aorta repaired at 11 months of age and betes mellitus and polycystic kidneys). Staphylococcus a bicuspid aortic valve was admitted to the hospital aureus or Enterobacteriaceae were responsible for most with a complaint of 3 weeks of fever. He was in infections, consistent with hematogenous and urinary excellent health until 3 weeks before admission when tract sources, respectively. No other cases of anaerobic he developed fever and transient lower back pain abscess were identified. This case highlights the impor- associated with lifting his backpack, which resolved tance of considering a renal abscess in the differential within 24 hours. There were no further back, muscle, diagnosis of fever of unknown origin and of processing or joint pains, but he continued to have daily fevers specimens for both aerobic and anaerobic organisms. Pediatrics 2001;107(1). URL: http://www.pediatrics.org/ that ranged between 38.5°C and 39.5°C. He was em- cgi/content/full/107/1/e11; fever of unknown origin, renal pirically treated with cephalexin orally, which was abscess, Peptostreptococcus asaccharolyticus. discontinued after 3 days because of gastric intoler- ance. His fevers persisted and he was admitted to the hospital for evaluation of FUO. Notably, 3 sets of ABBREVIATIONS. FUO, fever of unknown origin; MRI, magnetic resonance imaging; CT, computed tomography; CVA, costoverte- blood cultures obtained as an outpatient yielded no bral angle. growth. He had no history of previous dental proce- dures, bronchoscopy, or manipulation of the genito- urinary tract. However, he had lost 2 deciduous teeth enal abscesses are uncommon in pediatric pa- 2 weeks before the onset of fever. His physical ex- tients and rarely a cause of fever of unknown amination on admission was significant for a tem- 1–3 Rorigin (FUO). The infrequent occurrence of perature of 38.5°C and a pulse of 98 bpm. He had a this pathology poses a diagnostic challenge for phy- grade III/VI systolic murmur heard best in the apex, sicians and often results in delayed recognition and which was unchanged from previous examinations. 4 treatment. We recently cared for a child with a He had no hepatosplenomegaly. There were no pe- 3-week history of fevers. An indium scan ultimately techiae or signs of peripheral emboli or vasculitis. led to the diagnosis of a renal abscess. Aspiration His white cell count on admission was 14 700 with yielded a pure growth of the anaerobic Gram-posi- 45% of neutrophils and an erythrocyte sedimentation tive bacterium, Peptostreptococcus asaccharolyticus. rate of 98 mm/hour. This unusual case prompted a review of the pediatric Multiple blood and urine cultures yielded no literature and of patients cared for by the pediatric growth, and stool cultures showed normal enteric services at the Mount Sinai Medical Center over the flora. Urinalysis was normal. A chest radiograph was past 10 years. unremarkable. Two 2-dimensional and a multiplane transesophageal echocardiogram revealed a biscupid METHODS aortic valve with no vegetations. The possibility of an Seven additional cases of cortical or corticomedullary renal occult abscess was considered. An indium scan re- abscess were identified after review of discharge diagnoses of vealed a large defect in the superior pole of the right kidney. This was confirmed subsequently by a mag- From the Department of *Pediatrics and ‡Medicine, Mount Sinai School of netic resonance image (MRI) of the abdomen, which Medicine, New York, New York. showed an abscess (5.5 ϫ 3.6 ϫ 4.1 cm) in the upper Received for publication May 12, 2000; accepted Aug 16, 2000. pole of the right kidney (Fig 1). He was empirically Reprint requests to (V.A.M.C.) Division of Infectious Diseases, Box 1657, treated with intravenous nafcillin and gentamicin; Mount Sinai Medical Center, 1 Gustave L. Levy Pl, New York, NY 10029. E-mail: [email protected] nafcillin was replaced with clindamycin because of PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- intense venous discomfort during the infusion. He emy of Pediatrics. remained febrile despite antibiotic therapy and, http://www.pediatrics.org/cgi/content/full/107/1/Downloaded from www.aappublications.org/newse11 by guestPEDIATRICS on September Vol. 26, 2021 107 No. 1 January 2001 1of4 2of4 abscess. One patient had insulin-dependentmay diabetes, have contributed toof the development the of patients aullary renal abscesses had and 2 aThere had were cortical predisposing 5 abscesses. girls condition Onlypatients’ and 2 that ages 2 boys. ranged Fivesupporting from had the 4 rarity corticomed- ofmedical this diagnosis records (Table reviewed 1).sis over The of this 10-year renal period, abscess wereOther identified Cases among 43 224 isolate was identified as panel (Dade Behring, Inc, Westuse Sacramento, CA), the ofwith Mycroscan group F rapidEngland) and antisera. rendered anaerobic Biochemically, strongserotyped solitary through identification (Streptest, agglutination the Murexhemolytic Biotech activity LTD, about Dartford, theaerobically. colonies, the Because isolate of was thegrowth striking and was unsuspected absentdeveloped on blood after agarpact 72 plates colonies incubated hoursagar encircled of incubated by incubation, anaerobically,hours a small whereas on ( zone thioglycolatepairs of broth. and On shortous 5% aspirate chains. sheep showed Growth blood small occurred Gram-positive afterIsolation cocci 72 of in MRI revealed complete resolutiondiscontinued of after 3 the weeks abscess. ofweeks treatment. of A clindamycin follow-up andneous gentamicin; the drainage. latter was Thecharolyticus. patient receiveda pure a culture of totalrulent the fluid anaerobic of was streptococcus, removed, 6 tomography which subsequently (CT) grew guidance.therefore, Seven the milliliters abscess of was pu- drained under computed findings suggest a rightloculated cortical collection abscess. inFig the 1. upper pole of the right kidney. The Seven additional pediatric patients with a diagno- Gram-stained smears of the purulent percutane- Axial T2-weighted MRI image of the kidney showing a RENAL ABSCESS: RARE CAUSE OF FEVER OF UNKNOWN ORIGIN P asaccharolyticus The fever resolved 3 days after percuta- Downloaded from P asaccharolyticus 1 ⁄ 2 months to 19 years. www.aappublications.org/news ϳ 1 mm) com- ␤ . -hemolysis P asac- TABLE 1. Descriptive Data of Patients byguest on September26, 2021 Patient Type of Abscess Age and Signs and Underlying Urine Blood Abscess Urianalysis ESR Diagnostic Surgical Medication Sex Symptoms Conditions Culture Culture Culture Studies Intervention 1* Right cortical abscess 11 y; M 3-wk fever None Negative Negative P asaccharolyticus Normal 98 Indium scan Percutaneous Clindamycin, drainage gentamicin 2 Right cortical abscess 16 y; M 1-wk fever, IDDM Negative Negative MSSA Normal 53 Abdominal CT Percutaneous Ampicillin, CVA tenderness drainage gentamicin 3 Right corticomedullar 17 y; F 1-wk fever, dysuria None E coli Negative E coli 20 WBC, 15 RBC 91 Abdominal CT Percutaneous Ampicillin, abscess drainage gentamicin 4 Right corticomedullar 19 y; F 5-d fever, dysuria None E coli E coli Not done 20 WBC, 25 RBC 86 Abdominal None Cetriaxone, abscess ultrasound gentamicin 5 Left corticomedullary 18 y; F 2-d fever, abdominal PCKD P mirabilis Negative Not done 25 WBC, 10 RBC 70 Abdominal None Ampicillin, abscess pain ultrasound gentamicin 6 Left corticomedullary 15 y; F 2-d fever, Pregnancy E coli Negative Not done 25 WBC, 5 RBC 54 Abdominal None Ceftriaxone abscess CVA tenderness (5 mo) ultrasound 7 Right corticomedullar 4 mo, F 1-d fever, irritability None Negative Negative E coli Normal 74 Abdominal Percutaneous Ampicillin, abscess CT drainage gentamicin 8 Left cortical abscess 4 mo, M 2-wk fever, None Negative Negative MRSA Normal 144 Abdominal CT Nephrectomy Vancomycin weight loss PCKD indicates polycystic kidney disease; IDDM, insulin-dependent diabetes mellitus; MSSA, methicillin-susceptibles S aureus; MRSA, methicillin-resistant S aureus; ESR, erythrocyte sedimentation rate. * Index case. which is a common risk factor in adults; the other S aureus is the most common isolate in cortical patient had polycystic kidney disease. abscesses and has been found in 90% of reported Renal abscesses can result from hematogenous cases.5 This follows because most cortical abscesses spread or as a complication of infection from the result from hematogenous spread. This was proba- lower urinary tract.5,6 Patients 3, 4, 5, and 6 presum- bly the route of infection in 3 of 8 pediatric cases ably developed corticomedullary abscesses as a com- found in this review; cultures of 2 grew S aureus, plication of a urinary tract infection because they had whereas the index case was unusual because the symptoms of dysuria, costovertebral angle (CVA) culture yielded an anaerobe. Notably, in all 3 of these tenderness or abdominal pain, significant pyuria, cases the blood and urine cultures yielded no growth and a urine culture that grew Escherichia coli (3/4 and the urinalysis was normal. In contrast, cortico- cases) or Proteus mirabilis.
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