Rosen & Barkin's 5-Minute Emergency Medicine Consult (747 page)

• UTI may require lab confirmation of clinical suspicion. Signs and symptoms are often nonspecific.
  
• Febrile infants with UTI may be bacteremic.
  
• Neonates with UTI may have normal urinalysis.
  

• American Academy of Pediatrics, Subcommittee on Urinary Tract Infection. Urinary tract infection: Clinical practice guidelines for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.
  Pediatrics
  . 2011;128:595–610.
  
• Hoberman A, Keren R: Antimicrobial prophylaxis for urinary tract infection in children.
  N Engl J Med.
  2009;361:1804–1806.
  
• Marks SD, Gordon I, Tulls K. Imaging in childhood urinary tract infection: Time to reduce investigations.
  Pediatr Nephrol.
  2008;23:9–17.
  
• Peniakov M, Antonelli J, Naor O, et al. Reduction of contamination of urine samples obtained by in-out catheterization by culturing the later urine stream.
  Pediatr Emerg Care
  . 2004;6:418–419.
  
• Sahsi RS, Carpenter CR. Does this children have a urinary tract infection?
  Ann Emerg Med.
  2009;53:680–684.
  
• Wald E. Urinary tract infections in infants and children: A comprehensive overview.
  Curr Opin Pediatr
  . 2004;16:85–88.
  

See Also (Topic, Algorithm, Electronic Media Element)

UTI, Adult

CODES

• 041.49 Other and unspecified Escherichia coli [E. coli]
  
• 593.70 Vesicoureteral reflux unspecified or without reflux nephropathy
  
• 599.0 Urinary tract infection, site not specified
  

BASICS

• Cutaneous mast and basophil cellular release of inflammatory mediators, primarily histamine:
  
  • Increased vascular permeability and pruritus
    
• Edema of the epidermis as well as the upper and middle dermis:
  
  • More common in children and young adults
    
  • More common in women
    
  • More common in the atopic patient
    
• 40% of patients with urticaria will have a component of angioedema:
  
  • Affects deeper subdermal and/or submucosal sites
    

• Urticaria is often the result of reactions to foods and infections
  
• Swelling of distal extremities and acrocyanosis may be prominent in infants
  
• Bullae may form in the center of the wheal, especially on legs and buttocks
  

Acute:

Presumptive trigger may be found, but majority of cases are idiopathic

Course of <6 wk

• Drugs:
  
  • Few have recurrent urticaria on later antigenic challenge
    
• Foods or additives
  
• Herbal medications, vaccines, opiates
  
• Insect bites and stings
  
• Connective tissue diseases
  
• Endocrine disorders, especially Hashimoto’s thyroiditis
  
• Cancers, especially lymphoproliferative
  
• Hormonal imbalance, pregnancy, menstrual cycle, exogenous estrogens
  
• Infections:
  
  • Viral (including hepatitis, HIV)
    
  • Viral URI most common associated infection
    
  • Bacterial
    
  • Fungal
    
  • Parasitic
    
• Inhaled or contact allergen
  
• Emotional stress
  
• Physical urticaria—>20 identified types, including:
  
  • Dermographism:
    
    • Most common physical form
      
    • Reaction to skin pressure
      
    • Linear wheals under tight clothing
      
    • Areas scratched with a firm object
      
  • Cholinergic:
    
    • Monomorphic wheals 2–3 mm
      
    • Bright red flare and intense pruritus
      
  • A response to elevated core temperature:
    
    • Hot bath
      
    • Fever
      
    • Exercise
      
  • Other rare forms:
    
    • Cold-induced (may be fatal in cold immersions)
      
    • Sun exposure
      
    • Aquagenic
      

Chronic:

Course of >6 wk

• 75% idiopathic in nature
  
• Autoimmune disease spectrum
  
• Immune complex–induced
  
• Often an unrecognized recurring physical urticaria
  
• May be due to occult or subclinical infection or systemic disease
  

DIAGNOSIS

• Prior history
  
• Familial history
  
• Alleviating and/or aggravating factors
  
• Time course of current presentation:
  
  • Often helpful to circle lesions to document their duration
    
  • Fever and systemic symptoms
    
  • Arthralgias and myalgias
    
  • Weight loss and lymphadenopathy
    
  • Hypotension, flushing, headache
    
  • Swelling of mucosal sites
    
  • Respiratory distress or airway symptoms:
    
    • May be part of an anaphylactic reaction
      

• Focus on signs of systemic allergic reaction or infection
  
• Airway—angioedema, airway compromise, inability to handle secretions, abnormal phonation, stridor
  
• Breathing—wheezing
  
• Circulation—systemic signs of anaphylaxis, such as hypotension
  
• Abdomen—hepatosplenomegaly, pregnancy
  
• Dermal—associated edema, associated petechiae, or purpura:
  
  • Generalized, transient, pruritic, well-circumscribed skin eruptions
    
  • May include palms or soles
    
  • May include bullae or purpuric lesions
    
  • Lesions are of various sizes and shapes, haphazard in distribution, and may become confluent
    
  • Wheals usually resolve in 3–4 hr
    
  • New lesions evolve as old ones resolve
    
• Lymphadenopathy
  
• Dermographism:
  
  • Scratch skin with a tongue blade; observe for linear wheal
    
• Cholinergic:
  
  • Exercise challenge to raise core temperature or induce sweating
    
• Expose to sunlight
  
• Cold-induced:
  
  • Place an ice cube on skin for 5 min
    
• Aquagenic:
  
  • Apply tap water at differing temperatures
    
• Significant mucosal edema:
  
  • Suspect angioedema
    
  • Severe reaction with hypotension
    
  • Suspect anaphylaxis
    
• Prolonged, painful, or nonblanching lesions:
  
  • Suspect urticarial vasculitis
    

• Complete history and physical exam
  
• Lesion appearance, location, timing, duration
  
• Identify as acute vs. chronic time-course
  
• Associated symptoms, triggers
  
• Coexisting diseases, allergies, medications
  
• Evaluate for sources of infection and signs of systemic diseases
  

• Acute urticaria: No labs needed
  
• Chronic urticaria:
  
  • Evaluate for infection or systemic disease:
    
    • CBC with differential, ESR, and/or CRP
      
    • Thyroid-stimulating hormone and thyroid functions
      
    • Urinalysis, liver function tests
      
• Skin biopsy if urticarial vasculitis suspected (not done in ED)
  

• Acute cases: Not needed
  
• Chronic cases:
  
  • Directed at search for occult infection
    

Skin biopsy—for chronic urticaria or urticarial vasculitis

• Angioedema:
  
  • Can be life-threatening
    
  • May have component of abdominal symptoms
    
  • Hereditary or acquired
    
• Cutaneous vasculitis
  
• Serum sickness
  
• Erythema multiforme
  
• Bullous pemphigoid
  
• Juvenile rheumatoid arthritis
  
• Erythema marginatum
  
• Dermatitis herpetiformis
  
• Systemic mastocytosis
  
• Henoch–Schonlein purpura
  

TREATMENT