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Pyelonephritis
Sara M. O'Hara, MD, FAAP
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KEY FACTS

  • Terminology

    • Imaging

      • Clinical Issues

        TERMINOLOGY

        • Synonyms

          • Acute lobar nephronia, focal bacterial nephritis
        • Definitions

          • Acute infection of renal parenchyma
          • Overview
            • Classic imaging appearance: Focal swelling & ↓ perfusion of affected parenchyma visible on nuclear scintigraphy, US, CT, & MR
            • Associated with vesicoureteral reflux (VUR) in ~ 1/3 of cases
            • Permanent scarring more likely in children < 2 years old
            • Patients can have variable presentation: Fever, lethargy, irritability, vomiting, abdominal/flank pain, hematuria, or dysuria
          • Imaging work-up of urinary tract infection is controversial
            • See professional society guidelines, which vary internationally

        IMAGING

        • General Features

          • Radiographic Findings

            • Ultrasonographic Findings

              • CT Findings

                • MR Findings

                  • Nuclear Medicine Findings

                    • Imaging Recommendations

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Gross Pathologic & Surgical Features

                            • Microscopic Features

                              CLINICAL ISSUES

                              • Presentation

                                • Demographics

                                  • Natural History & Prognosis

                                    • Treatment

                                      DIAGNOSTIC CHECKLIST

                                      • Consider

                                        • Image Interpretation Pearls

                                          Selected References

                                          1. Arlen AM et al: Computer model predicting breakthrough febrile urinary tract infection in children with primary vesicoureteral reflux. J Pediatr Urol. ePub, 2016
                                          2. Zhang GQ et al: The effect of vitamin A on renal damage following acute pyelonephritis in children: a meta-analysis of randomized controlled trials. Pediatr Nephrol. 31(3):373-9, 2016
                                          3. de Bessa J Jr et al: Antibiotic prophylaxis for prevention of febrile urinary tract infections in children with vesicoureteral reflux: a meta-analysis of randomized, controlled trials comparing dilated to nondilated vesicoureteral reflux. J Urol. 193(5 Suppl):1772-7, 2015
                                          4. Morello W et al: Acute pyelonephritis in children. Pediatr Nephrol. 31(8):1253-65, 2015
                                          5. Narchi H et al: Renal tract abnormalities missed in a historical cohort of young children with UTI if the NICE and AAP imaging guidelines were applied. J Pediatr Urol. 11(5):252.e1-7, 2015
                                          6. Shaikh N et al: Procalcitonin, C-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children. Cochrane Database Syst Rev. 1:CD009185, 2015
                                          7. Sood A et al: Incidence, admission rates, and economic burden of pediatric emergency department visits for urinary tract infection: data from the nationwide emergency department sample, 2006 to 2011. J Pediatr Urol. 11(5):246.e1-8, 2015
                                          8. Cerwinka WH et al: Comparison of magnetic resonance urography to dimercaptosuccinic acid scan for the identification of renal parenchyma defects in children with vesicoureteral reflux. J Pediatr Urol. 10(2):344-51, 2014
                                          9. Jacobson D et al: Perinephric abscesses in the pediatric population: case presentation and review of the literature. Pediatr Nephrol. 29(5):919-25, 2014
                                          10. Strohmeier Y et al: Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. 7:CD003772, 2014
                                          11. Yang TH et al: Obesity and a febrile urinary tract infection: dual burden for young children? Urology. 84(2):445-9, 2014
                                          12. La Scola C et al: Different guidelines for imaging after first UTI in febrile infants: yield, cost, and radiation. Pediatrics. 131(3):e665-71, 2013
                                          13. Leroy S et al: Association of procalcitonin with acute pyelonephritis and renal scars in pediatric UTI. Pediatrics. 131(5):870-9, 2013
                                          14. Prabhu A et al: Pyelonephritis: what are the present day causative organisms and antibiotic susceptibilities? Nephrology (Carlton). 18(6):463-7, 2013
                                          15. Shaikh N et al: Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics. 126(6):1084-91, 2010
                                          16. Brenner M et al: Comparison of 99mTc-DMSA dual-head SPECT versus high-resolution parallel-hole planar imaging for the detection of renal cortical defects. AJR Am J Roentgenol. 193(2):333-7, 2009
                                          17. Siomou E et al: Implications of 99mTc-DMSA scintigraphy performed during urinary tract infection in neonates. Pediatrics. 124(3):881-7, 2009
                                          18. Cerwinka WH et al: Magnetic resonance urography in pediatric urology. J Pediatr Urol. 4(1):74-82; quiz 82-3, 2008
                                          19. Gonzalez E et al: Impact of vesicoureteral reflux on the size of renal lesions after an episode of acute pyelonephritis. J Urol. 173(2):571-4; discussion 574-5, 2005
                                          20. Wang YT et al: Correlation of renal ultrasonographic findings with inflammatory volume from dimercaptosuccinic acid renal scans in children with acute pyelonephritis. J Urol. 173(1):190-4; discussion 194, 2005
                                          21. Hoberman A et al: Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 348(3):195-202, 2003
                                          22. Maturen KE et al: Computed tomographic diagnosis of unsuspected pyelonephritis in children. Can Assoc Radiol J. 53(5):279-83, 2002
                                          23. Kraus SJ: Genitourinary imaging in children. Pediatr Clin North Am. 48(6):1381-424, 2001
                                          24. Majd M et al: Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model. Radiology. 218(1):101-8, 2001
                                          25. Roberts KB: A synopsis of the American Academy of Pediatrics' practice parameter on the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatr Rev. 20(10):344-7, 1999
                                          26. Yen TC et al: Identification of new renal scarring in repeated episodes of acute pyelonephritis using Tc-99m DMSA renal SPECT. Clin Nucl Med. 23(12):828-31, 1998
                                          27. Winters WD: Power Doppler sonographic evaluation of acute pyelonephritis in children. J Ultrasound Med. 15(2):91-6; quiz 97-8, 1996
                                          28. AAP Gateway: Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Published August, 2011. Accessed May 2016.
                                          29. NICE: NICE guidelines. Published August 2007. Accessed May 2016.
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Clinical Issues

                                                TERMINOLOGY

                                                • Synonyms

                                                  • Acute lobar nephronia, focal bacterial nephritis
                                                • Definitions

                                                  • Acute infection of renal parenchyma
                                                  • Overview
                                                    • Classic imaging appearance: Focal swelling & ↓ perfusion of affected parenchyma visible on nuclear scintigraphy, US, CT, & MR
                                                    • Associated with vesicoureteral reflux (VUR) in ~ 1/3 of cases
                                                    • Permanent scarring more likely in children < 2 years old
                                                    • Patients can have variable presentation: Fever, lethargy, irritability, vomiting, abdominal/flank pain, hematuria, or dysuria
                                                  • Imaging work-up of urinary tract infection is controversial
                                                    • See professional society guidelines, which vary internationally

                                                IMAGING

                                                • General Features

                                                  • Radiographic Findings

                                                    • Ultrasonographic Findings

                                                      • CT Findings

                                                        • MR Findings

                                                          • Nuclear Medicine Findings

                                                            • Imaging Recommendations

                                                              DIFFERENTIAL DIAGNOSIS

                                                                PATHOLOGY

                                                                • General Features

                                                                  • Gross Pathologic & Surgical Features

                                                                    • Microscopic Features

                                                                      CLINICAL ISSUES

                                                                      • Presentation

                                                                        • Demographics

                                                                          • Natural History & Prognosis

                                                                            • Treatment

                                                                              DIAGNOSTIC CHECKLIST

                                                                              • Consider

                                                                                • Image Interpretation Pearls

                                                                                  Selected References

                                                                                  1. Arlen AM et al: Computer model predicting breakthrough febrile urinary tract infection in children with primary vesicoureteral reflux. J Pediatr Urol. ePub, 2016
                                                                                  2. Zhang GQ et al: The effect of vitamin A on renal damage following acute pyelonephritis in children: a meta-analysis of randomized controlled trials. Pediatr Nephrol. 31(3):373-9, 2016
                                                                                  3. de Bessa J Jr et al: Antibiotic prophylaxis for prevention of febrile urinary tract infections in children with vesicoureteral reflux: a meta-analysis of randomized, controlled trials comparing dilated to nondilated vesicoureteral reflux. J Urol. 193(5 Suppl):1772-7, 2015
                                                                                  4. Morello W et al: Acute pyelonephritis in children. Pediatr Nephrol. 31(8):1253-65, 2015
                                                                                  5. Narchi H et al: Renal tract abnormalities missed in a historical cohort of young children with UTI if the NICE and AAP imaging guidelines were applied. J Pediatr Urol. 11(5):252.e1-7, 2015
                                                                                  6. Shaikh N et al: Procalcitonin, C-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children. Cochrane Database Syst Rev. 1:CD009185, 2015
                                                                                  7. Sood A et al: Incidence, admission rates, and economic burden of pediatric emergency department visits for urinary tract infection: data from the nationwide emergency department sample, 2006 to 2011. J Pediatr Urol. 11(5):246.e1-8, 2015
                                                                                  8. Cerwinka WH et al: Comparison of magnetic resonance urography to dimercaptosuccinic acid scan for the identification of renal parenchyma defects in children with vesicoureteral reflux. J Pediatr Urol. 10(2):344-51, 2014
                                                                                  9. Jacobson D et al: Perinephric abscesses in the pediatric population: case presentation and review of the literature. Pediatr Nephrol. 29(5):919-25, 2014
                                                                                  10. Strohmeier Y et al: Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. 7:CD003772, 2014
                                                                                  11. Yang TH et al: Obesity and a febrile urinary tract infection: dual burden for young children? Urology. 84(2):445-9, 2014
                                                                                  12. La Scola C et al: Different guidelines for imaging after first UTI in febrile infants: yield, cost, and radiation. Pediatrics. 131(3):e665-71, 2013
                                                                                  13. Leroy S et al: Association of procalcitonin with acute pyelonephritis and renal scars in pediatric UTI. Pediatrics. 131(5):870-9, 2013
                                                                                  14. Prabhu A et al: Pyelonephritis: what are the present day causative organisms and antibiotic susceptibilities? Nephrology (Carlton). 18(6):463-7, 2013
                                                                                  15. Shaikh N et al: Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics. 126(6):1084-91, 2010
                                                                                  16. Brenner M et al: Comparison of 99mTc-DMSA dual-head SPECT versus high-resolution parallel-hole planar imaging for the detection of renal cortical defects. AJR Am J Roentgenol. 193(2):333-7, 2009
                                                                                  17. Siomou E et al: Implications of 99mTc-DMSA scintigraphy performed during urinary tract infection in neonates. Pediatrics. 124(3):881-7, 2009
                                                                                  18. Cerwinka WH et al: Magnetic resonance urography in pediatric urology. J Pediatr Urol. 4(1):74-82; quiz 82-3, 2008
                                                                                  19. Gonzalez E et al: Impact of vesicoureteral reflux on the size of renal lesions after an episode of acute pyelonephritis. J Urol. 173(2):571-4; discussion 574-5, 2005
                                                                                  20. Wang YT et al: Correlation of renal ultrasonographic findings with inflammatory volume from dimercaptosuccinic acid renal scans in children with acute pyelonephritis. J Urol. 173(1):190-4; discussion 194, 2005
                                                                                  21. Hoberman A et al: Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 348(3):195-202, 2003
                                                                                  22. Maturen KE et al: Computed tomographic diagnosis of unsuspected pyelonephritis in children. Can Assoc Radiol J. 53(5):279-83, 2002
                                                                                  23. Kraus SJ: Genitourinary imaging in children. Pediatr Clin North Am. 48(6):1381-424, 2001
                                                                                  24. Majd M et al: Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model. Radiology. 218(1):101-8, 2001
                                                                                  25. Roberts KB: A synopsis of the American Academy of Pediatrics' practice parameter on the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatr Rev. 20(10):344-7, 1999
                                                                                  26. Yen TC et al: Identification of new renal scarring in repeated episodes of acute pyelonephritis using Tc-99m DMSA renal SPECT. Clin Nucl Med. 23(12):828-31, 1998
                                                                                  27. Winters WD: Power Doppler sonographic evaluation of acute pyelonephritis in children. J Ultrasound Med. 15(2):91-6; quiz 97-8, 1996
                                                                                  28. AAP Gateway: Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Published August, 2011. Accessed May 2016.
                                                                                  29. NICE: NICE guidelines. Published August 2007. Accessed May 2016.