Nephrology


        

Case Discussion

Hemanturia / urinary track infection / renal-angle pains   Posted By Shreedhar Sahoo    Date : 07-Feb-07   10:43 AM     Reply

CASE HISTORY OF SHREEDHAR SAHOO, MALE-64 YRS

1. TYPE-II, Diabetic since last 20 years 2. Suffered from a mild heart attack in 1995. 3. Had an Angioplasty surgery with sterling in the right artery in 1997. 4. Suffered from Cervical Spondilitis during in 1998-99. 5. Undergone by-pass surgery (CABG) with four grafts in April-2003. 6. From August-2003 till date suffering from continuous urinary track infections with periodical intermittent mild fever. Had an episode of Hemanturia on 15th August-2203. Ultrasound / Sonography conducted immediately within an hour of bleeding, revealed the melting away/ coagulating of a blood clot at the right urator-bladder junction. Within an hour, bleeding stopped and clear urine came. No further Hemanturia/Bleeding thereafter till now. 7. Repeated ultrasound tests conducted thereafter, reveals that there is no mass-lesion/stone/tumor, anywhere in any organ of the whole of abdomen. All organs are normal in the size/ shape functioning, except mild enlargement of prostrate glands (low-bar prostratogamy) with defused thickening of bladder walls. Residual urine is 20-25cc only. 8. Systoscopy of the bladder conducted within a month-two, thereafter, confirmed the above fact and revealed the bladder full of pus-cells. 9. As urologists advice was not in favor of surgical operation of prostrate glands, continuing on medications till now. 10. With several types of antibiotics, tried according to repeated urine culture reports(C/S) both oral/injunction (such as Gatifloxacin, Livofloxacin, Amikacin with adcef, Nitrofuration etc.) the quantity of pus-cells is coming down to 5-6/HPF; but again increasing when the medicine is discontinued. 11. The urine culture reports reveals the existence of E-Colli bacteria, which are becoming resistant to such medicines. Even Homeopathic prescriptions advising Teribinth-30, Uva-Urse Q-30, Sabalser Q-30, Chimaphil U-Q-30 and subsequent trial of Methylin blue, Pyrogen, cantharis, Ferrum Picric, Perrava Brava have ended with the same results, i.e. pus-cells decreasing with medicines and increasing with discontinuances of medicine. 12. Persistence of pus-cells, possibly due to existence of T.B, was suspected by Urologist. But this possibility was also eliminated after several tests conducted for T.B Doctor concluded that it is normal E-Colli infection in the bladder and prescribed for long-term administration of Nitrofurntoin Tablets on low doses; along with good control of blood sugar. Accordingly continued this treatment for a year or more but of no-use. With injection of insulin, fasting blood sugar (FBS) is around110-120, while PPBS is around 180-200. 13. During the last one & half year, had Renal-Angle pains (location of Kidney/Lever), 3 to 4 times, some times on the left side and some times on the right. The pain was however tolerable and stopped after a day or two, with one or two painkillers or so. The local medicine specialists suspected these to be Diabetic Neuropathy and advised for better control of blood sugar. On last 15/1/2007, the pain was on right side and was very acute/severe, almost intolerable; associated with high fever/rigger. Urologists conducted all types of clinical tests, Urine-Culture &R/M, Ultrasound, X-ray plain, and Contrast IVP, etc. All such tests indicated no abnormality in the KUB area. He referred my case to Gastro-Entrology. Gastro-Entrology prescriptions did not relive the pain. 14. Then consulted Nephrologists. After examination of all test reports, he suspected it to be Renal Papilla necrosis and asked for C-T scans of Kidneys. As per culture report of urine, he prescribed a course of strong antibiotic injections (Piperacilin+Toza). With this injection, fever / rigger immediately stopped and level of pus-cells in the urine reduced from 15-16/HPF to 8-10/HPF. FBS was only 102 and PPBS (without insulin) was 315. But the pain, though reduced considerably, is still persisting about 20-25%, even now. The C-T scans report, thereafter revealed no abnormalities in the kidneys/Lever/urator/bladder etc. except the same findings of earlier ultrasound reports, i.e mild enlargement of prostrate glands, defused thickening of bladder walls and narrowing of right urator after the starting point. No calcification was also detected anywhere. Doctors suspicion of Renal-Papilla-Necrosis was also not there. Then Doctor suggested for better control of Blood Sugar and low dose antibiotic like Nitro-Furantoin-50 mg or Septran single strength for 3 months to bring down the level of pus-cells. This has been tried earlier, but in vain. His view was that due to Blood Sugar the bacteria are persisting/ growing and pus-cell level is increasing. This is the same line of diagnosis as of the Urologists done earlier. And 15. This does not answer the question in my mind- Why the Renal Angle pain? Is the pain due to high pus-cell level in the bladder? If not, then what is the real cause of this pain and how it can be cured? If yes, how can the pus-cells/ persisting infection be totally eliminated? Or the pain is related to any other cause, such as Neuro/Gastro/Spine etc.


Replies to the above case discussion :

Re : Hemanturia / urinary track infection / renal-angle pains - Sandip Mitra 10-Feb-07    05:58 AM




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