No abstract

A 12-month-old boy presented to our hospital with <24-h history of high-grade fevers and asymmetrical facial expression (day 1). This occurred on the background of a 5-day period of low-grade fevers and coryza.Physical examination showed peripheral facial nerve palsy (FNP) and acute otitis media (AOM) in the right ear (Fig. 1). He had no protruding auricle, pharyngitis, cervical lymphadenopathy, erythema, abdominal masses or abnormality of other nerves. Computed tomography of the head showed fluid accumulation in bilateral mastoid antra. White blood cell count was 13,700/μL (neutrophils 25.5%, lymphocytes 61.9%, monocytes 12.3%, basophils 0.3%) and C-reactive protein level was 10.81 mg/dL. The number of cells in cerebrospinal fluid (CSF) was 10/μL (mononuclear cells 10/μL, polymorphonuclear cells 0/μL), protein concentration was 13 g/dL, glucose level was 69 mg/dL. No bacteria were detected from blood or CSF cultures.We diagnosed FNP due to otomastoiditis and started the patient on cefotaxime (180 mg/kg/day), prednisolone (2.0 mg/kg/day) and acyclovir (45 mg/kg/day).FNP improved and fever resolved on day 3. The patient still had no pharyngitis, cervical lymphadenopathy or systemic erythema. However, the same day, we palpated an elastic, firm, smooth and painless mass in the left upper quadrant of the abdomen. We therefore conducted ultrasonography, revealing mild splenomegaly. In addition, white blood cell count increased to 20,800/μL, while C-reactive protein level decreased to 1.2 mg/dL. Atypical lymphocytes were seen in blood smears (12%). CD4/CD8 ratio was decreased to 0.4. We excluded the possibility of leukaemia or lymphoma by flowcytometry. These findings were most consistent with infectious mononucleosis (IM).

Background: The gold standard for the diagnosis of acute pyelonephritis (APN) in children is the finding of both pyuria (P) and bacteriuria (B); however, some APN patients have neither of these findings [APN(P(−);B(−))]. Methods: In this study, we investigated APN patients who visited our hospital over 14 years to identify specific clinical characteristics of APN(P(−);B(−)). Results: A total of 171 APN patients were included in the study, and of these 29 were APN(P(−);B(−)). Of the APN(P(−);B(−)) patients, 25.9% had vesicoureteral reflux (VUR), the same percentage as the APN(P(+);B(+)) patients, and 69.0% of APN(P(−);B(−)) patients had already taken antibiotics before diagnosis. APN(P(−);B(−)) patients were older and had a longer duration between onset of fever and diagnosis than the patients with pyuria and/or bacteriuria. In addition, they showed higher C-reactive protein levels. APN(P(−);B(−)) patients had high levels of urinary α-1 microglobulin and urinary β-2 microglobulin. Conclusions: APN is difficult to diagnose in febrile patients who display neither pyuria nor bacteriuria, but as these patients have the same risk for VUR as APN patients with pyuria and bacteriuria, a detailed history establishing the clinical course as well as urinary chemistry investigations, may assist in diagnosis.