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Abacterial Pyuria: Response to Aureomycin
THE JOURNAL OF UroLOGY
Vol. 63, No. 5, May, 1950
Printed in U. S, A.
ABACTERIAL PYURIA: RESPONSE TO AUREOMYCIN STACY M. HANKEY
AND
RAYMOND STEPT
Abacterial pyuria has been so lucidly described in a number of excellent reports disease is now being clinically recognized without difficulty. Any acute urinary tract infection characterized· by bladder symptoms and sterile urine despite the presence of pyuria now immediately suggests abacterial pyuria. Bacteriologic studies have led most observers to presume that a virus, probably related to the agent causing Reiter's disease, is responsible. The beneficial effect of neo-arsphenamine has been r~'cognized for at least 30 years, but the recent discovery of a succession of chemotherapeutic and antibiotic agents has stimulated the hope that in one of these a rapid, specific cure would be found. However, the sulfa compounds, then· penicillin, have been worthless. Recently, streptomycin was used in several patients, but with results that were rather equivocal. Aureomycin, the newest antibiotic available commercially, must now be appraised in its application to this disease. The following 2 cases, though too few in number to warrant premature enthusiasm, demonstrate a response to aureomycin which should encourage further trial and obs«;irvations. In both of these cases bacteriological studies were made to exclude tuberculosis and to rule out other bacterial infections. Sulfadiazine and penicillin were used without effect in both patients, and mapharse11 in one.
1ri tb:e 'past few years that what had been a puzzling
c4sE REPORTS
Case 1. H. M., a white. married man, aged 49, was first seen in April 1949. Mild hesitancy in voiding had been present for 2 months. One month previously he noticed a mild urethral discharge which subsided spontaneously after 2 days. Five days ago he experienced terminal hematuria at several voidings, and severe urgency, frequency, and nocturia began 48 hours later. There were no constitutional symptoms. The urine was so heavily laden with pus cells that it was almost milky in appearance, yet odorless. Physical examination disclosed moderate congestion and slight tenderness of the prostate, but was otherwise negative. Cystoscopy disclosed that the bladder was of markedly reduced capacity. There was generalized mucosal edema involving the entire surface of the bladder and prostatic urethra, and, in addition, a white pseudomembrane overlying the trigone which bled easily with manipulation of the panendoscope. Intravenous urography disclosed normal function on both sides and gave excellent visualization. There was slight dilatation of both ureters and renal pelves, and slight tortuosity of the lower portions of both ureters. The blood Wassermann was negative, and examination of the blood revealed a mild leukocytosis. Cultures of the bladder urine on three sucessive days were sterile. Searches for acid fast organisms in the urine were negative, and acid fast cultures were later reported as negative. Therapy was begun with full dosage of sulfadiazine and penicillin for 5 days 912
ABACTERIAL PYURIA: RESPONSE TO AUREOMYCIN
913
without response. Intravenous mapharsen 0.4 mg. was administered intravenously, but 48 hours later there was still no significant alleviation of symptoms. Therefore, aureomycin was begun. in doses of 250 mg. every 6 hours for 12 doses. Pronounced symptomatic improvement was apparent within 12 hours. Within 48 hours all symptoms had completely disappeared, and the urine was free of all abnormal elements. Checkup cystoscopy 1 week later revealed that the bladder had returned to normal except for a small area of congestion on the dome. The prostate was still slightly tender, and the prostato-vesicular fluid contained 20 to 25 white blood cells per high power field. Several urinalyses in the past 9 months have been negative. Case 2. H. S., a Negro, aged 29 years, was first seen in June 1949. Three weeks previously he had a mucoid urethral discharge which had diminished after two prostatic massages given by his family physician. Ten days previously he began to have terminal hematuria accompanied by severe urgency, frequency, and nocturia, and these symptoms had persisted despite full doses of sulfadiazine and penicillin given by his family physician. There were no constitutional symptoms. Urinalysis disclosed 2 plus albumin and many red and white blood cells. Physical examination was negative except for slight congestion and tenderness of the right lobe of the prostate, and a slight mucoid urethral secretion which contained no organisms. Cystoscopy revealed a bladder of markedly reduced capacity with diffuse congestion of the entire mucosa, and numerous areas of submucosal hemorrhage; there was generalized superficial edema of the prostatic urethra. Intravenous urography showed excellent function bilaterally with morphologically normal kidneys, and a contracted but smooth bladder outline. Bladder urine cultures on two successive days were sterile. Smears and cultures for acid fast bacilli were negative. Therapy with aureomycin, 250 mg. every 6 hours, was initiated. The response was again dramatic. Urinary symptoms began to diminish in 24 hours, and 96 hours later had disappeared completely. Urinalysis at this time was negative, and cystoscopy disclosed that the bladder had returned to normal except for two very small hemorrhagic areas on the dome. Eight months later the patient was still asymptomatic. COMMENT
The cases cited above lend support to the impression that abacterial pyuria probably has its origin in the prostate or prostatic urethra and involves the bladder by direct extension. On the strong presumption that the condition is a virus infection it was believed that aureomycin, which is efficacious in several virus infections, might be effective. The response in both instances was no less than dramatic, not only in the relief of symptoms, but in the rapid clearing of the urine, and healing of the bladder and urethra. The response to intravenous arsenicals, on the other hand, is usually slower, and the disappearance of pus from the urine often delayed for several weeks to several months. Possibly similar results may be expected in the treatment of Reiter's disease since it has such a pronounced resemblance to abacterial pyuria.
914
STACY M. HANKEY AND RAYMOND STEPT SUMMARY
.Two cases of a bacterial pyuria which responded immediately to aureomycin therapy have been described. 8012 Jenkins Bldg., Pittsburgh, Pa. (S. M. H.) 3500 Fifth Ave., Pittsburgh, Pa. (R. S.) REFERENCES 1939.
BRAASCH, W. F.: Am. J. Surg., 45: 472, BRIGGS, W. I.: J. Urol. 34: 230, 1935. COLBY, F.: J. Urol., 52: 415, 1944.
CooK, E. N.: J. Urol., 36: 460, 1936. GRoss, S.: Wien. klin. Wchnschr., 30: 1381, 1917. HAMM, F. C.: J. Urol., 67: 226, 1947. LANDES, R.R. AND RANSON, C. L.: J. Urol., 60: 666, 1948. MooRE, T.: J. Urol., 49: 203, 1943. SOLOMON, A. A.: J. Urol., 59: 252, 1948.
Vol. 63, No. 5, May, 1950
Printed in U. S, A.
ABACTERIAL PYURIA: RESPONSE TO AUREOMYCIN STACY M. HANKEY
AND
RAYMOND STEPT
Abacterial pyuria has been so lucidly described in a number of excellent reports disease is now being clinically recognized without difficulty. Any acute urinary tract infection characterized· by bladder symptoms and sterile urine despite the presence of pyuria now immediately suggests abacterial pyuria. Bacteriologic studies have led most observers to presume that a virus, probably related to the agent causing Reiter's disease, is responsible. The beneficial effect of neo-arsphenamine has been r~'cognized for at least 30 years, but the recent discovery of a succession of chemotherapeutic and antibiotic agents has stimulated the hope that in one of these a rapid, specific cure would be found. However, the sulfa compounds, then· penicillin, have been worthless. Recently, streptomycin was used in several patients, but with results that were rather equivocal. Aureomycin, the newest antibiotic available commercially, must now be appraised in its application to this disease. The following 2 cases, though too few in number to warrant premature enthusiasm, demonstrate a response to aureomycin which should encourage further trial and obs«;irvations. In both of these cases bacteriological studies were made to exclude tuberculosis and to rule out other bacterial infections. Sulfadiazine and penicillin were used without effect in both patients, and mapharse11 in one.
1ri tb:e 'past few years that what had been a puzzling
c4sE REPORTS
Case 1. H. M., a white. married man, aged 49, was first seen in April 1949. Mild hesitancy in voiding had been present for 2 months. One month previously he noticed a mild urethral discharge which subsided spontaneously after 2 days. Five days ago he experienced terminal hematuria at several voidings, and severe urgency, frequency, and nocturia began 48 hours later. There were no constitutional symptoms. The urine was so heavily laden with pus cells that it was almost milky in appearance, yet odorless. Physical examination disclosed moderate congestion and slight tenderness of the prostate, but was otherwise negative. Cystoscopy disclosed that the bladder was of markedly reduced capacity. There was generalized mucosal edema involving the entire surface of the bladder and prostatic urethra, and, in addition, a white pseudomembrane overlying the trigone which bled easily with manipulation of the panendoscope. Intravenous urography disclosed normal function on both sides and gave excellent visualization. There was slight dilatation of both ureters and renal pelves, and slight tortuosity of the lower portions of both ureters. The blood Wassermann was negative, and examination of the blood revealed a mild leukocytosis. Cultures of the bladder urine on three sucessive days were sterile. Searches for acid fast organisms in the urine were negative, and acid fast cultures were later reported as negative. Therapy was begun with full dosage of sulfadiazine and penicillin for 5 days 912
ABACTERIAL PYURIA: RESPONSE TO AUREOMYCIN
913
without response. Intravenous mapharsen 0.4 mg. was administered intravenously, but 48 hours later there was still no significant alleviation of symptoms. Therefore, aureomycin was begun. in doses of 250 mg. every 6 hours for 12 doses. Pronounced symptomatic improvement was apparent within 12 hours. Within 48 hours all symptoms had completely disappeared, and the urine was free of all abnormal elements. Checkup cystoscopy 1 week later revealed that the bladder had returned to normal except for a small area of congestion on the dome. The prostate was still slightly tender, and the prostato-vesicular fluid contained 20 to 25 white blood cells per high power field. Several urinalyses in the past 9 months have been negative. Case 2. H. S., a Negro, aged 29 years, was first seen in June 1949. Three weeks previously he had a mucoid urethral discharge which had diminished after two prostatic massages given by his family physician. Ten days previously he began to have terminal hematuria accompanied by severe urgency, frequency, and nocturia, and these symptoms had persisted despite full doses of sulfadiazine and penicillin given by his family physician. There were no constitutional symptoms. Urinalysis disclosed 2 plus albumin and many red and white blood cells. Physical examination was negative except for slight congestion and tenderness of the right lobe of the prostate, and a slight mucoid urethral secretion which contained no organisms. Cystoscopy revealed a bladder of markedly reduced capacity with diffuse congestion of the entire mucosa, and numerous areas of submucosal hemorrhage; there was generalized superficial edema of the prostatic urethra. Intravenous urography showed excellent function bilaterally with morphologically normal kidneys, and a contracted but smooth bladder outline. Bladder urine cultures on two successive days were sterile. Smears and cultures for acid fast bacilli were negative. Therapy with aureomycin, 250 mg. every 6 hours, was initiated. The response was again dramatic. Urinary symptoms began to diminish in 24 hours, and 96 hours later had disappeared completely. Urinalysis at this time was negative, and cystoscopy disclosed that the bladder had returned to normal except for two very small hemorrhagic areas on the dome. Eight months later the patient was still asymptomatic. COMMENT
The cases cited above lend support to the impression that abacterial pyuria probably has its origin in the prostate or prostatic urethra and involves the bladder by direct extension. On the strong presumption that the condition is a virus infection it was believed that aureomycin, which is efficacious in several virus infections, might be effective. The response in both instances was no less than dramatic, not only in the relief of symptoms, but in the rapid clearing of the urine, and healing of the bladder and urethra. The response to intravenous arsenicals, on the other hand, is usually slower, and the disappearance of pus from the urine often delayed for several weeks to several months. Possibly similar results may be expected in the treatment of Reiter's disease since it has such a pronounced resemblance to abacterial pyuria.
914
STACY M. HANKEY AND RAYMOND STEPT SUMMARY
.Two cases of a bacterial pyuria which responded immediately to aureomycin therapy have been described. 8012 Jenkins Bldg., Pittsburgh, Pa. (S. M. H.) 3500 Fifth Ave., Pittsburgh, Pa. (R. S.) REFERENCES 1939.
BRAASCH, W. F.: Am. J. Surg., 45: 472, BRIGGS, W. I.: J. Urol. 34: 230, 1935. COLBY, F.: J. Urol., 52: 415, 1944.
CooK, E. N.: J. Urol., 36: 460, 1936. GRoss, S.: Wien. klin. Wchnschr., 30: 1381, 1917. HAMM, F. C.: J. Urol., 67: 226, 1947. LANDES, R.R. AND RANSON, C. L.: J. Urol., 60: 666, 1948. MooRE, T.: J. Urol., 49: 203, 1943. SOLOMON, A. A.: J. Urol., 59: 252, 1948.