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Urinary tract infection due to Hemophilus influenzae, type b
414
4.
5.
6.
7. :
Brief clinical and laboratory observations
The Journal of Pediatrics March 1974
stimulating hormone, J. Clin. Endocrinol. Metab. 27: 295, 1967. Faiman, C., and Ryan, R. J.: Radioimmunoassay for human follicle-stimulating hormone, J. Clin. Endocrinol. Metab. 27: 444, 1967. Greenwood, F. C., Hunter, W. N., and Glover, J. S.: The preparation of 1-131 labelled human growth hormone of high specific activity, Biochem. J. 89: 114, 1963. Callow, N. H., Callow, R. K., and Emmens, C. W.: Colorimetric determination of substances containing the grouping--CH2CO--in urine extracts as an indication of androgen content, Biochem. J. 32: 1312, 1938. Wilkins, L., Blizzard, R. M., and Migeon, C. G., editors: The diagnosis and treatment of endocrine disorders in childhood and adolescence, ed. 3, Springfield, lllinois,
1965, Charles C Thomas, Publisher, pp. 37 and 408. Barraclough, C. A.: Modifications in the CNS regulation of reproduction after exposure of prepubertal rats to steroid hormones, Recent Progr. Horm. Res. 22: 503, 1966. 9. Dupon, C., and Schwartz, N. B.: Pituitary LH patterns in prepubertal normal and testosterone sterilized rats, Neuroendocrinology 7: 236, 1971. 10. Mallampati, R. S., and Johnson, D. C.: Serum and pituitary prolactin, LH, and FSH in androgenized female and normal male rats treated with various doses of estradiol benzoate, Neuroendocrinology 11: 46, 1973. 11. Bogumil, R. J., Ferin, M., and Vande Wiele, R. L.: Mathematical studies of the human menstrual cycle. II. Stimulation performance of a model of the human menstrual cycle, J. Clin. Endocrinol. Metab. 35: 144, 1973.
Urinary tract infection due to Hemophilus influenzae, type b
added. H. influenzae is characterized by: (1) the requirem e n t f o r g r o w t h of both X and V factors, (2) the absence of hemolysis on blood agar, and (3) the presence of a capsule. T h e presence of a capsule, as well as its antigenic type, is d e t e r m i n e d by mixing one drop of a suspension of organisms with one drop of specific antiserum, types " a " t h r o u g h " f " (Difco L a b o r a t o r i e s , D e t r o i t , Mich.). Microscopic observation of capsular swelling (Quellung reaction) in the presence o f a specific antiserum serves to subclassify the organism. 4
Report o.f two cases
Dan M. Granoff, M.D., Cleveland, Ohio, and Saul Roskes, M.D.,* Baltimore, Md.
8.
CASE REPORTS R E C E N T reviews 1, 2 of infections in children due to Hemophilus influenzae m a k e no m e n t i o n of its possible occurrence in urinary tract infections. During the past eight years, two children with urinary tract infections due to H. influenzae, type b, were seen at T h e J o h n s Hopkins Hospital. In each of the children the diagnosis was unrecognized initially because: (1) H. influenzae will not grow readily in standard media r e c o m m e n d e d 3 to process routine urine cultures (sheep's blood agar and M a c C o n k e y ' s or e o s i n - m e t h y l e n e blue [EMB] media) and (2) there is a lack of appreciation that 1t. in[tuenzae is a potential pathogen in the urinary tract. MATERIALS
AND METHODS
H. influenzae, after isolation on chocolate agar, was identified by colony morphology and G r a m stain. Specific identification of 11. influenzae is carried out routinely in our laboratory by streaking the surface o f a h u m a n blood agar plate and a tryptocase soy agar plate. Paper strips containing X factor, V factor, and X + V factors are From the Department of Pediatrics, Johns Hopkins UniversitySchool of Medicine. *Reprintaddress:Departmentof Pediatrics, TheJohnsHopkins Hospital, Baltimore, Md. 21205.
Case 1. P. J., a Caucasian boy, was admitted in June, 1965, at the age of 3 10/12years, because of a two-week history of fever, abdominal pain, and "sterile" pyuria. In the outpatient department, urinalysis had shown 2+ protein and 30 to 40 white blood cells per high-power field. There had been no growth of bacteria in two urine cultures. An intravenous pyelogram demonstrated radiolucen/~ striations within the renal pelvis and collecting system of the left kidney consistent with mucosal edema associated with acute pyelonephritis. Because additional urine cultures were negative, he was given no specific therapy but was admitted to the hospital for further evaluation. His past medical history was unrernarkable except for frequent episodes of otitis media, but no infection had occurred within the previous month. There was no history suggestive of recent renal trauma. Physical examination revealed a toxic-appearing child with height and weight in the fiftieth percentile for age. Vital signs were a heart rate of 140, respirations 24, temperature 39.8~ C., and blood pressure 120170 mm. Hg. His tympanic membranes were scarred. He had mild guarding of the abdomen with tenderness extending to the left flank. The remainder of the physical examination was not remarkable. Laboratory data were as follows: hematocrit, 31 per cent; hemoglobin, 10.1 Gin. per cent; white blood count, 36,700 per cubic millimeter: 6 per cent juveniles, 81 per cent neutrophils, 7 per cent lymphocytes, and 6 per cent monoeytes; erytbrocyte
Volume 84 Number 3 sedimentation rate, 27 mm. per hour, corrected (Wintrobe). Intermediate PPD was negative. Urinalysis showed pyuria and proteinuria. A single Gram stain was allegedly negative. Ten additional negative urine cultures were obtained. On the ninth hospital day, three weeks after the first onset of symptoms, H. in)quenzae, type b, was identified while utilizing multiple media for the purpose of isolating protoplasts. This was confirmed by inoculation of three additional urine specimens on chocolate agar, with growth of H. influenzae, type b, in numbers greater than 100,000 colonies per milliliter. A cystourethrogram showed bilateral ureteral reflux. The clinical response to ampicillin and chloramphenicol therapy was rapid, with prompt sterilization of the urine. He has had no further urinary tract infections during the subsequent eight years. Because of persistent left ureteral reflux he underwent reimplantation of the left ureter in 1967. An intravenous pyelogram in 1971 showed minimal caliectasis on the left; unchanged from previous studies. The creatinine clearance in 1971 was 126 c.c. per millimeter per 1.73 square meters. Case 2. M. E. a 4 6/12-year-old Caucasian girl, was referred in May~ 1971, for evaluation of short stature. The patient's growth and development had been normal throughout the first two years of life. Thereafter, she increased in height only 288 inches. There were no other signs of illness, no unexplained fever or urinary symptoms, and no history of renal trauma. She was a bright and alert child with proportionate short stature; her height (35.3 inches) and weight (26 pounds) were below the third percentile. Vital signs were normal except for an elevated blood pressure of 130/90 mm. Hg in upper and lower extremities. She had some of the facial features of Noonan's syndrome. 5 Laboratory data included the following: hematocrit, 38 per cent; hemoglobin, 12.6 Gm. per cent; white blood count 9,800 per cubic millimeter; erythrocyte sedimentation rate, 45 ram. per hour (Wintrobe). An electrocardiogram and chest radiograph were normal. Intermediate PPD was negative. A buccai smear was chromatin positive. A suprapubic specimen of urine had a specific gravity of 1.005, pH 6, 3+ albumin, and no acetone or reducing substance. There were one to five red blood cells and 15 to 20 white blood cells per high-power field. Numerous gram-negative rods were present on the Gram stain but cultures of two urine specimens on standard media were negative. Three days later another sample was obtained and incubated on chocolate agar, as well as on the routine media for urine cultures. H, influenzae, type b, grew on the chocotate agar in colony counts of greater than ,100,000 per milliliter, while the routine plates contained no growth. This was confirmed on two additional specimens. Additional studies showed the child to have chronic metabolic acidosis, hyperphosphatemia, and azotemia. The creatinine clearance was 11.6 ml. per minute per 1.73 square meter. The kidneys were poorly visualized by intravenous pyelogram, but appeared small and symmetric. Bilateral ureteral reflux was present on the voiding cystourethrogram. Voiding pattern was normal, and no residual urine was demonstrable. Cystoscopy was also normal.
Brief clinical and laboratory observations
415
She was treated with ampicillin, which resulted m prompt sterilization of urine. She was then discharged on continuous therapy with phosphate binders (aluminum hydroxide) and ant acids (sodium citrate). There were no further urinary tract infections. In April, 1972, the patient received a kidney transplant donated by her mother. DISCUSSION T h e two cases illustrate s o m e o f t h e pitfalls e n c o u n tered in d i a g n o s i n g tl. influenzae u r i n a r y tract infections. T h e first p a t i e n t p r e s e n t e d w i t h acute, toxic pyelonephritis; the second had no symptoms except short s t a t u r e f r o m a d v a n c e d renal disease. Delay in diagnosis occurred in each child. T h e lack o f appreciation o f H. infiuenzae as a u r i n a r y p a t h o g e n r e s u l t e d in failure to include m e d i a a p p r o p r i a t e for t h e identification o f this organism. C h o c o l a t e agar has b e e n e m p l o y e d widely for isolation of H. #![tuenzae a n d it was u s e d successfully to identify t h e o r g a n i s m f r o m t h e u r i n e o f each o f our patients. It is n o t a b l e t h a t t h e latest edition o f the Manual o f clinical microbiology r e c o m m e n d s that, for t h e diagnosis o f urin a r y tract infection, u r i n e s h o u l d b e p r o c e s s e d r o u t i n e l y e i t h e r by accurate bacterial q u a n t i t a t i o n by s u s p e n d i n g a s a m p l e in t r y p t o c a s e soy agar or by s t r e a k i n g with a q u a n t i t a t i v e loop o n s h e e p ' s blood agar a n d MacC o n k e y ' s or E M B media. 3 N o n e of t h e s e will readily s u p p o r t g r o w t h o f H. influenzae. H. influenzae requires two specific factors for g r o w t h , t h e so-called X a n d V factors. 6, 7 T h e X factor has b e e n dentified as h e m i n ; t h e V factor is replaceable as D P N F P N , or n i c o t i n a m i d e nucleoside. A l t h o u g h s h e e p ' s b l o o d agar c o n t a i n s t h e s e s u b s t a n c e s , they are largely u n a v a i l a b l e to t h e o r g a n i s m . Intracellular h e m i n (X factor) m u s t b e released f r o m t h e cells b e f o r e it b e c o m e s available. M o r e o v e r , V factor is readily d e s t r o y e d by heat-labile e n z y m e s d e r i v e d fl'om intact red b l o o d cells. T h e r e f o r e , h e a t i n g t h e b l o o d agar to p r o d u c e chocolate agar b o t h releases the h e m i n by lysing the cells a n d d e n a t u r e s t h e hydrolytic e n z y m e s . A l t h o u g h H . influenzae will grow well o n u n h e a t e d r a b b i t or g u i n e a pig b l o o d agar, u n h e a t e d horse, sheep, a n d h u m a n b l o o d are i n h i b i t i n g ; delayed g r o w t h o f t h e o r g a n i s m , h o w e v e r , m a y be o b s e r v e d o n s h e e p ' s b l o o d agar. T h e r e are relatively few w e l l - d o c u m e n t e d reports of u r i n a r y tract infections due to H. influenzae. 8 T h e first cases were r e p o r t e d in adults in t h e early part o f this century. 9-11It was n o t until 1960 t h a t eight children with this e n t i t y were identified. 12 F o u r o f t h e m h a d s e v e r e u n derlying disease w i t h o b s t r u c t i v e uropathy; o n e h a d a renal stone. One patient had advanced, chronic p y e l o n e p h r i t i s with a s t a g h o r n calculus. O n e h a d i m p e r forate anus, rectovesical fistula, p e r m a n e n t c o l o s t o m y ,
416
Brief cfinical and laboratory observations
and indwelling catheter. The remaining two patients had a history o f severe renal trauma just prior to b e c o m i n g infected. In five patients, other organisms were found simultaneously. In each case tested, the H e m o p h i l u s was nonencapsulated. The two patients in the present report differ from those reported previously ~2 in that (1) there was no evidence of obstructive uropathy, renal calculi, or recent severe trauma; (2) encapsulated type b H. 01fluenzae, usually associated with respiratory, meningeal, and joint infections, was found. T h e incidence of H. influenzae urinary tract infections remains to be ascertained. Ih the study by K u n i n and associates, 13 in which large n u m b e r s of school children were screened for urinary tract infection, H. influenzae could not have been d e m o n s t r a t e d by their methods. This was true also in the m o r e recent study by Savage and colleagues. 14It is possible that hemophilus infections are unrecognized m o r e frequently than is appreciated, since the organism is not identified usually with routine culture techniques on unheated sheep's blood agar, MacC o n k e y ' s , or E M B media. This organism, as well as Mycobacterium tuberculosis and others with fastidious growth requirements, should be suspected w h e n one is c o n f r o n t e d with pyuria without demonstrable bacteriuria. C o n s i d e r a t i o n s h o u l d be g i v e n to m o r e widespread use of chocolate agar in the processing of urine cultures. We are indebted to Dr. David Carver for helpful suggestions in reviewing this manuscript, to Dr. Patricia Charache for recognizing Hemophilus while she was attempting to isolate protoplasts from Case 1, and to Dr. Robert Blizzard for allowing us to study his patient, our Case 2 (M. E.).
The Journal of Pediatrics March 1974
2. Alexander, H. E.: Hemophilus influenzae infections, in Cooke, R. E., editor: The biologic basis of pediatric practice, New York, 1968, McGraw-Hill Book Co., Inc., pp. 732-743. 3. Blair, J. E., Lennette, E. H., and Truant, J. P., editors: Manual of clinical microbiology, Baltimore, 1970, The Williams & Wilkins Company, p. 53. 4. Ibid: p. 216. 5. Noonan, J. A., and Ehmke, D. B.: Associated non-cardiac malformations in children with congenital heart disease. J PEDRATk.63: 468, 1963 (abst.). 6. Davis, B. D.: Dulbecco, R., Eisen, H. N., Ginsberg, H. S., and Wood, W. B.: Microbiology, New York, 1967, Harper & Row, Publishers, pp. 790-795. 7. Turk, D. C., and May, J. R.: Haemophilus influenzae: Its clinical importance, London, 1967, English Univerisities Press, Ltd., p. 5. 8. Ibid.: p. 67. 9. Wright, J. D.: An observation on the occurrence of the bacillus of influenza (Bacterium influenzae) in pyelonephrosis, Boston Med. Surg. J. 152: 496, 1905. 10. Davis, D. J.: A hemophilic bacillus found in urinary infections, J. Infect. Dis. 7: 599, 1910. ll. Albright, F., Dienes, L., and Sulkowitch, H. W.: Pyelonephritis with nephrocalcinosis caused by Haemophilas influenzae and alleviated by sulfanilamide: report of two cases, J. A. M. A. 110: 357, 1938. 12. Rogers, K. B., Zinnemann, K., and Foster, W. P.: The isolation and identification of Haemophilus Spp. from unusual lesions in children, J. Clin. Pathol. 13: 519, 1960. 13. Kunin, C. M., Deutscher, R., and Paquin, A.: Urinary tract infection in school children: An epidemiologic, clinical, and laboratory study, Medicine 43: 91, 1964. 14. Savage, D. C. L., Wilson, M. I., McHardy, M., Dewar, D. A. E., and Fee, W. M.: Covert bacteriuria of childhood: A clinical and epidemiologic study, Arch. Dis. Child. 48: 8, 1973.
REFERENCES
1. Sell, S. H.: The clinical importance of Hemophilus influenzae infections in children, Pediatr. Clin. North Am. 17: 415, 1970.
Wilms' tumor metastasis to uncommon sites Nasser Movassaghi, M.D.,* Sanford Leikin, M.D., and Roma Chandra, M.D.,
Washington, D. C.
From the Section of Hematology/Oncology and Pathology of the Children's Hospital National Medical Center and the George Washington University School of Medicine. *Reprint address: 2125 13th St. N. W., Washington,D. C. 20009.
T H E CO M M O N sites of metastases in Wilms' t u m o r are regional l y m p h nodes, lungs, and liver. Metastasis to b o n e marrow, bones, and secretory glands is very rare. Recently we h a v e observed a child with W i l m s ' tumor who developed metastases t o unusual sites, including bones, bone marrow, parotid gland, and tonsils, which were detected by biopsy. CASE REPORT
A 389 girl was admitted to the Children's Hospital National Medical Center with a large nontender abdominal mass noted one week previously. The physical examination was unremarkable except for a large mass in the left side of the abdomen. Intravenous pyelography and an inferior venocavogram were suggestive of a Wilms' tumor of the left kidney. The
4.
5.
6.
7. :
Brief clinical and laboratory observations
The Journal of Pediatrics March 1974
stimulating hormone, J. Clin. Endocrinol. Metab. 27: 295, 1967. Faiman, C., and Ryan, R. J.: Radioimmunoassay for human follicle-stimulating hormone, J. Clin. Endocrinol. Metab. 27: 444, 1967. Greenwood, F. C., Hunter, W. N., and Glover, J. S.: The preparation of 1-131 labelled human growth hormone of high specific activity, Biochem. J. 89: 114, 1963. Callow, N. H., Callow, R. K., and Emmens, C. W.: Colorimetric determination of substances containing the grouping--CH2CO--in urine extracts as an indication of androgen content, Biochem. J. 32: 1312, 1938. Wilkins, L., Blizzard, R. M., and Migeon, C. G., editors: The diagnosis and treatment of endocrine disorders in childhood and adolescence, ed. 3, Springfield, lllinois,
1965, Charles C Thomas, Publisher, pp. 37 and 408. Barraclough, C. A.: Modifications in the CNS regulation of reproduction after exposure of prepubertal rats to steroid hormones, Recent Progr. Horm. Res. 22: 503, 1966. 9. Dupon, C., and Schwartz, N. B.: Pituitary LH patterns in prepubertal normal and testosterone sterilized rats, Neuroendocrinology 7: 236, 1971. 10. Mallampati, R. S., and Johnson, D. C.: Serum and pituitary prolactin, LH, and FSH in androgenized female and normal male rats treated with various doses of estradiol benzoate, Neuroendocrinology 11: 46, 1973. 11. Bogumil, R. J., Ferin, M., and Vande Wiele, R. L.: Mathematical studies of the human menstrual cycle. II. Stimulation performance of a model of the human menstrual cycle, J. Clin. Endocrinol. Metab. 35: 144, 1973.
Urinary tract infection due to Hemophilus influenzae, type b
added. H. influenzae is characterized by: (1) the requirem e n t f o r g r o w t h of both X and V factors, (2) the absence of hemolysis on blood agar, and (3) the presence of a capsule. T h e presence of a capsule, as well as its antigenic type, is d e t e r m i n e d by mixing one drop of a suspension of organisms with one drop of specific antiserum, types " a " t h r o u g h " f " (Difco L a b o r a t o r i e s , D e t r o i t , Mich.). Microscopic observation of capsular swelling (Quellung reaction) in the presence o f a specific antiserum serves to subclassify the organism. 4
Report o.f two cases
Dan M. Granoff, M.D., Cleveland, Ohio, and Saul Roskes, M.D.,* Baltimore, Md.
8.
CASE REPORTS R E C E N T reviews 1, 2 of infections in children due to Hemophilus influenzae m a k e no m e n t i o n of its possible occurrence in urinary tract infections. During the past eight years, two children with urinary tract infections due to H. influenzae, type b, were seen at T h e J o h n s Hopkins Hospital. In each of the children the diagnosis was unrecognized initially because: (1) H. influenzae will not grow readily in standard media r e c o m m e n d e d 3 to process routine urine cultures (sheep's blood agar and M a c C o n k e y ' s or e o s i n - m e t h y l e n e blue [EMB] media) and (2) there is a lack of appreciation that 1t. in[tuenzae is a potential pathogen in the urinary tract. MATERIALS
AND METHODS
H. influenzae, after isolation on chocolate agar, was identified by colony morphology and G r a m stain. Specific identification of 11. influenzae is carried out routinely in our laboratory by streaking the surface o f a h u m a n blood agar plate and a tryptocase soy agar plate. Paper strips containing X factor, V factor, and X + V factors are From the Department of Pediatrics, Johns Hopkins UniversitySchool of Medicine. *Reprintaddress:Departmentof Pediatrics, TheJohnsHopkins Hospital, Baltimore, Md. 21205.
Case 1. P. J., a Caucasian boy, was admitted in June, 1965, at the age of 3 10/12years, because of a two-week history of fever, abdominal pain, and "sterile" pyuria. In the outpatient department, urinalysis had shown 2+ protein and 30 to 40 white blood cells per high-power field. There had been no growth of bacteria in two urine cultures. An intravenous pyelogram demonstrated radiolucen/~ striations within the renal pelvis and collecting system of the left kidney consistent with mucosal edema associated with acute pyelonephritis. Because additional urine cultures were negative, he was given no specific therapy but was admitted to the hospital for further evaluation. His past medical history was unrernarkable except for frequent episodes of otitis media, but no infection had occurred within the previous month. There was no history suggestive of recent renal trauma. Physical examination revealed a toxic-appearing child with height and weight in the fiftieth percentile for age. Vital signs were a heart rate of 140, respirations 24, temperature 39.8~ C., and blood pressure 120170 mm. Hg. His tympanic membranes were scarred. He had mild guarding of the abdomen with tenderness extending to the left flank. The remainder of the physical examination was not remarkable. Laboratory data were as follows: hematocrit, 31 per cent; hemoglobin, 10.1 Gin. per cent; white blood count, 36,700 per cubic millimeter: 6 per cent juveniles, 81 per cent neutrophils, 7 per cent lymphocytes, and 6 per cent monoeytes; erytbrocyte
Volume 84 Number 3 sedimentation rate, 27 mm. per hour, corrected (Wintrobe). Intermediate PPD was negative. Urinalysis showed pyuria and proteinuria. A single Gram stain was allegedly negative. Ten additional negative urine cultures were obtained. On the ninth hospital day, three weeks after the first onset of symptoms, H. in)quenzae, type b, was identified while utilizing multiple media for the purpose of isolating protoplasts. This was confirmed by inoculation of three additional urine specimens on chocolate agar, with growth of H. influenzae, type b, in numbers greater than 100,000 colonies per milliliter. A cystourethrogram showed bilateral ureteral reflux. The clinical response to ampicillin and chloramphenicol therapy was rapid, with prompt sterilization of the urine. He has had no further urinary tract infections during the subsequent eight years. Because of persistent left ureteral reflux he underwent reimplantation of the left ureter in 1967. An intravenous pyelogram in 1971 showed minimal caliectasis on the left; unchanged from previous studies. The creatinine clearance in 1971 was 126 c.c. per millimeter per 1.73 square meters. Case 2. M. E. a 4 6/12-year-old Caucasian girl, was referred in May~ 1971, for evaluation of short stature. The patient's growth and development had been normal throughout the first two years of life. Thereafter, she increased in height only 288 inches. There were no other signs of illness, no unexplained fever or urinary symptoms, and no history of renal trauma. She was a bright and alert child with proportionate short stature; her height (35.3 inches) and weight (26 pounds) were below the third percentile. Vital signs were normal except for an elevated blood pressure of 130/90 mm. Hg in upper and lower extremities. She had some of the facial features of Noonan's syndrome. 5 Laboratory data included the following: hematocrit, 38 per cent; hemoglobin, 12.6 Gm. per cent; white blood count 9,800 per cubic millimeter; erythrocyte sedimentation rate, 45 ram. per hour (Wintrobe). An electrocardiogram and chest radiograph were normal. Intermediate PPD was negative. A buccai smear was chromatin positive. A suprapubic specimen of urine had a specific gravity of 1.005, pH 6, 3+ albumin, and no acetone or reducing substance. There were one to five red blood cells and 15 to 20 white blood cells per high-power field. Numerous gram-negative rods were present on the Gram stain but cultures of two urine specimens on standard media were negative. Three days later another sample was obtained and incubated on chocolate agar, as well as on the routine media for urine cultures. H, influenzae, type b, grew on the chocotate agar in colony counts of greater than ,100,000 per milliliter, while the routine plates contained no growth. This was confirmed on two additional specimens. Additional studies showed the child to have chronic metabolic acidosis, hyperphosphatemia, and azotemia. The creatinine clearance was 11.6 ml. per minute per 1.73 square meter. The kidneys were poorly visualized by intravenous pyelogram, but appeared small and symmetric. Bilateral ureteral reflux was present on the voiding cystourethrogram. Voiding pattern was normal, and no residual urine was demonstrable. Cystoscopy was also normal.
Brief clinical and laboratory observations
415
She was treated with ampicillin, which resulted m prompt sterilization of urine. She was then discharged on continuous therapy with phosphate binders (aluminum hydroxide) and ant acids (sodium citrate). There were no further urinary tract infections. In April, 1972, the patient received a kidney transplant donated by her mother. DISCUSSION T h e two cases illustrate s o m e o f t h e pitfalls e n c o u n tered in d i a g n o s i n g tl. influenzae u r i n a r y tract infections. T h e first p a t i e n t p r e s e n t e d w i t h acute, toxic pyelonephritis; the second had no symptoms except short s t a t u r e f r o m a d v a n c e d renal disease. Delay in diagnosis occurred in each child. T h e lack o f appreciation o f H. infiuenzae as a u r i n a r y p a t h o g e n r e s u l t e d in failure to include m e d i a a p p r o p r i a t e for t h e identification o f this organism. C h o c o l a t e agar has b e e n e m p l o y e d widely for isolation of H. #![tuenzae a n d it was u s e d successfully to identify t h e o r g a n i s m f r o m t h e u r i n e o f each o f our patients. It is n o t a b l e t h a t t h e latest edition o f the Manual o f clinical microbiology r e c o m m e n d s that, for t h e diagnosis o f urin a r y tract infection, u r i n e s h o u l d b e p r o c e s s e d r o u t i n e l y e i t h e r by accurate bacterial q u a n t i t a t i o n by s u s p e n d i n g a s a m p l e in t r y p t o c a s e soy agar or by s t r e a k i n g with a q u a n t i t a t i v e loop o n s h e e p ' s blood agar a n d MacC o n k e y ' s or E M B media. 3 N o n e of t h e s e will readily s u p p o r t g r o w t h o f H. influenzae. H. influenzae requires two specific factors for g r o w t h , t h e so-called X a n d V factors. 6, 7 T h e X factor has b e e n dentified as h e m i n ; t h e V factor is replaceable as D P N F P N , or n i c o t i n a m i d e nucleoside. A l t h o u g h s h e e p ' s b l o o d agar c o n t a i n s t h e s e s u b s t a n c e s , they are largely u n a v a i l a b l e to t h e o r g a n i s m . Intracellular h e m i n (X factor) m u s t b e released f r o m t h e cells b e f o r e it b e c o m e s available. M o r e o v e r , V factor is readily d e s t r o y e d by heat-labile e n z y m e s d e r i v e d fl'om intact red b l o o d cells. T h e r e f o r e , h e a t i n g t h e b l o o d agar to p r o d u c e chocolate agar b o t h releases the h e m i n by lysing the cells a n d d e n a t u r e s t h e hydrolytic e n z y m e s . A l t h o u g h H . influenzae will grow well o n u n h e a t e d r a b b i t or g u i n e a pig b l o o d agar, u n h e a t e d horse, sheep, a n d h u m a n b l o o d are i n h i b i t i n g ; delayed g r o w t h o f t h e o r g a n i s m , h o w e v e r , m a y be o b s e r v e d o n s h e e p ' s b l o o d agar. T h e r e are relatively few w e l l - d o c u m e n t e d reports of u r i n a r y tract infections due to H. influenzae. 8 T h e first cases were r e p o r t e d in adults in t h e early part o f this century. 9-11It was n o t until 1960 t h a t eight children with this e n t i t y were identified. 12 F o u r o f t h e m h a d s e v e r e u n derlying disease w i t h o b s t r u c t i v e uropathy; o n e h a d a renal stone. One patient had advanced, chronic p y e l o n e p h r i t i s with a s t a g h o r n calculus. O n e h a d i m p e r forate anus, rectovesical fistula, p e r m a n e n t c o l o s t o m y ,
416
Brief cfinical and laboratory observations
and indwelling catheter. The remaining two patients had a history o f severe renal trauma just prior to b e c o m i n g infected. In five patients, other organisms were found simultaneously. In each case tested, the H e m o p h i l u s was nonencapsulated. The two patients in the present report differ from those reported previously ~2 in that (1) there was no evidence of obstructive uropathy, renal calculi, or recent severe trauma; (2) encapsulated type b H. 01fluenzae, usually associated with respiratory, meningeal, and joint infections, was found. T h e incidence of H. influenzae urinary tract infections remains to be ascertained. Ih the study by K u n i n and associates, 13 in which large n u m b e r s of school children were screened for urinary tract infection, H. influenzae could not have been d e m o n s t r a t e d by their methods. This was true also in the m o r e recent study by Savage and colleagues. 14It is possible that hemophilus infections are unrecognized m o r e frequently than is appreciated, since the organism is not identified usually with routine culture techniques on unheated sheep's blood agar, MacC o n k e y ' s , or E M B media. This organism, as well as Mycobacterium tuberculosis and others with fastidious growth requirements, should be suspected w h e n one is c o n f r o n t e d with pyuria without demonstrable bacteriuria. C o n s i d e r a t i o n s h o u l d be g i v e n to m o r e widespread use of chocolate agar in the processing of urine cultures. We are indebted to Dr. David Carver for helpful suggestions in reviewing this manuscript, to Dr. Patricia Charache for recognizing Hemophilus while she was attempting to isolate protoplasts from Case 1, and to Dr. Robert Blizzard for allowing us to study his patient, our Case 2 (M. E.).
The Journal of Pediatrics March 1974
2. Alexander, H. E.: Hemophilus influenzae infections, in Cooke, R. E., editor: The biologic basis of pediatric practice, New York, 1968, McGraw-Hill Book Co., Inc., pp. 732-743. 3. Blair, J. E., Lennette, E. H., and Truant, J. P., editors: Manual of clinical microbiology, Baltimore, 1970, The Williams & Wilkins Company, p. 53. 4. Ibid: p. 216. 5. Noonan, J. A., and Ehmke, D. B.: Associated non-cardiac malformations in children with congenital heart disease. J PEDRATk.63: 468, 1963 (abst.). 6. Davis, B. D.: Dulbecco, R., Eisen, H. N., Ginsberg, H. S., and Wood, W. B.: Microbiology, New York, 1967, Harper & Row, Publishers, pp. 790-795. 7. Turk, D. C., and May, J. R.: Haemophilus influenzae: Its clinical importance, London, 1967, English Univerisities Press, Ltd., p. 5. 8. Ibid.: p. 67. 9. Wright, J. D.: An observation on the occurrence of the bacillus of influenza (Bacterium influenzae) in pyelonephrosis, Boston Med. Surg. J. 152: 496, 1905. 10. Davis, D. J.: A hemophilic bacillus found in urinary infections, J. Infect. Dis. 7: 599, 1910. ll. Albright, F., Dienes, L., and Sulkowitch, H. W.: Pyelonephritis with nephrocalcinosis caused by Haemophilas influenzae and alleviated by sulfanilamide: report of two cases, J. A. M. A. 110: 357, 1938. 12. Rogers, K. B., Zinnemann, K., and Foster, W. P.: The isolation and identification of Haemophilus Spp. from unusual lesions in children, J. Clin. Pathol. 13: 519, 1960. 13. Kunin, C. M., Deutscher, R., and Paquin, A.: Urinary tract infection in school children: An epidemiologic, clinical, and laboratory study, Medicine 43: 91, 1964. 14. Savage, D. C. L., Wilson, M. I., McHardy, M., Dewar, D. A. E., and Fee, W. M.: Covert bacteriuria of childhood: A clinical and epidemiologic study, Arch. Dis. Child. 48: 8, 1973.
REFERENCES
1. Sell, S. H.: The clinical importance of Hemophilus influenzae infections in children, Pediatr. Clin. North Am. 17: 415, 1970.
Wilms' tumor metastasis to uncommon sites Nasser Movassaghi, M.D.,* Sanford Leikin, M.D., and Roma Chandra, M.D.,
Washington, D. C.
From the Section of Hematology/Oncology and Pathology of the Children's Hospital National Medical Center and the George Washington University School of Medicine. *Reprint address: 2125 13th St. N. W., Washington,D. C. 20009.
T H E CO M M O N sites of metastases in Wilms' t u m o r are regional l y m p h nodes, lungs, and liver. Metastasis to b o n e marrow, bones, and secretory glands is very rare. Recently we h a v e observed a child with W i l m s ' tumor who developed metastases t o unusual sites, including bones, bone marrow, parotid gland, and tonsils, which were detected by biopsy. CASE REPORT
A 389 girl was admitted to the Children's Hospital National Medical Center with a large nontender abdominal mass noted one week previously. The physical examination was unremarkable except for a large mass in the left side of the abdomen. Intravenous pyelography and an inferior venocavogram were suggestive of a Wilms' tumor of the left kidney. The