TOW #46: Hematuria

Until recommendations changed in 2008, pediatricians routinely performed urinalysis screening in otherwise healthy children. This is no longer recommended, so we may not encounter microscopic hematuria quite as often. However, knowledge of how we approach hematuria in the outpatient setting is helpful to review given the possibility of medical complications.

Materials for this week:

Take-home points for this week on hematuria (for this,focused on the heme part, but case also reviews the protein part):

  1. Definition of hematuria: presence of 5 or more RBCs per high-power (40) field in 3 consecutive fresh, centrifuged specimens obtained over several weeks. There is microscopic (visible only on testing) or macroscopic (gross) hematuria (visible to the eye). Beware of false hematuria from drugs, foods (e.g.,beets, blackberries), toxins (e.g., lead), and urate crystals in newborns.
  2. Epidemiology: population studies in Finland and Texas have shown a prevalence of 3-6% of asymptomatic microscopic hematuria in school-age children in a single urine sample. With repeat screenings, prevalence declines to 0.5% to 1%. There are no differences by race/ethnicity. Until 2008, the AAP recommended urine screening routinely at age 5 and during adolescence, but this was ended due to low rates of disease and high false positives.
  3. Types of hematuria: Diagnostic evaluation depends on the category: gross hematuria, symptomatic microscopic hematuria, asymptomatic microscopic hematuria with proteinuria, or isolated asymptomatic microscopic hematuria. Evaluating RBC morphology helps distinguish glomerular and extraglomerular sources. Glomerular bleeding is typically “cola-colored,” with RBC casts and distorted RBC morphology.
  4. Hematuria type determines need for work-up: see the above algorithm. We have to distinguish between asymptomatic microscopic hematuria which is usually benign and requires conservative management, and hematuria with accompanying proteinuria, edema, hypertension, or other symptoms which suggests underlying renal disease. Underlying causes of gross hematuria are identified in 56% of cases including UTI, trauma, kidney stones, hypercalciuria, coagulopathy and kidney disease.
  5. Initial next steps: Repeat the urine test with microscopy, identify other symptoms, and review family history of renal disease. For persistent proteinuria, a morning and evening urine will be needed to identify orthostatic proteinuria, which accounts for 60% of asymptomatic proteinuria cases. If the patient has any markers of serious glomerular pathology, a basic metabolic panel, CBC, C3, C4, albumin, ANA, anti-streptolysin (ASO) and anti-DNAse B titers, and streptozyme would be recommended.

TOW #45: Lymphadenopathy

This week’s topic is a review of lymphadenopathy and how to characterize those lumps and bumps that parents worry about (and us too!). Interesting fact of the day: there are about 600 lymph nodes in the body! One of the fascinating zebras on the differential for lymphadenopathy is Kikuchi disease, a necrotizing lymphadenitis, recently reviewed in an excellent morning report by R3 Josiah Peterson MD PhD.

The teaching materials for the week:

Take-home points on lymphadenopathy:

  1. What’s the definition of lymphadenopathy? Abnormality in size, number, or consistency of lymph nodes (whereas lymphadenitis is an inflammatory or infectious enlargement of lymph nodes). Lymph nodes are normally up to 1cm in the axillary and cervical regions and up to 1.5cm in the inguinal region. “Shotty lymphadenopathy” refers to multiple small, mobile lymph nodes resembling birdshot (~2mm) or buckshot (~8mm) under the skin. This is a common, self-limited finding in children under five typically during viral illnesses. Any node >2cm should be considered abnormal. Generalized lymphadenopathy refers to two or more noncontiguous sites of lymph node enlargement.
  2. Why lymph?: An “ultrafiltrate” of blood, lymph carries immune cells in lymph capillaries through the entire body except the brain and heart. The bone marrow and thymus are the primary lymphoid organs because they generate B and T lymphocytes. Secondary lymphoid organs are lymph nodes, spleen, and mucosa-associated lymphoid tissue (MALT), including the tonsils, appendix, and Peyer patches of the ileum. Because young children’s immune systems are actively developing, we commonly feel enlarged lymph nodes.
  3. What’s on the differential diagnosis? The broad categories are infectious, immune disorders, and malignancy. Under age 5, we know cervical lymph nodes are almost always infectious-don’t forget scalp and dental sources. Supraclavicular nodes are always abnormal, most commonly caused by lymphoma, mycobacterial infection, or sarcoidosis. Generalized lymph node swelling is more likely to be systemic infection (viruses, including EBV, CMV, HIV, syphilis or toxoplasmosis), but also may be a sign of malignancy or autoimmune disorders.
  4. What are key parts of history and physical exam? Ask about systemic symptoms, including fever, weight loss, night sweats, poor appetite, and fatigue. Ask about the time course, and change in the size or number of lymph nodes. Review exposure to insects, animal contacts, travel, and immunizations. Determine locations of lymph nodes, whether unilateral versus bilateral, soft versus hard, mobile versus fixed, and tender versus non-tender. Focus the rest of the exam on chief complaint/symptoms. More worrisome signs for malignancy include hard/ rubbery, immobile, persistent and non-tender lymph nodes (though malignant ones can also be tender).
  5. When should we do a work-up and what should it include? If nothing suggests malignancy, observe for 2-4 weeks, then follow-up. If not resolved, work-up would include viral serologies and CBC, ESR and CRP. Additional testing is done based on history (e.g., Bartonella henselae PCR when concerns for cat scratch, or TB testing for patients at risk). When there is concern for malignancy, including prolonged duration, location, large or increasing size, abnormal texture, and/or the presence of constitutional symptoms, we should refer for biopsy and obtain CXR to look for mediastinal lymphadenopathy.

TOW #44: Transition to adult care

R3s will soon be making their own big transitions into jobs and fellowships! Likewise, our adolescent/young adult patients will soon experience notable transitions as they graduate and move on to new adventures. Transitions for some of our patients with special health care needs require additional support, which we will review in this week’s topic. Big thanks to Dr. Peter Asante for his contributions to his topic!

Materials for this week:

Take Home Points:

  1. Why is transition of care important? Every year, about 500,000 adolescents transition from pediatric to adult care. For children with special healthcare needs, this is the highest risk time for health complications and poor outcomes. Some studies have shown that continued care at pediatric medical centers (after age 21) can lead to higher risk of mortality. Transition involves both assuming self-management of medical care (when appropriate for the patient’s abilities) and transfer of medical summary/ documentation.
  2. When should transition process start? 2011 joint guidelines on transitions of care recommend the following schedule as a general guide:
    • Age 12-13: Start discussing the transition process with teens and parents. Provide a copy of office Transition Policy. (To me this is REALLY early for primary care, so I am more likely to wait to mid- to late teens, depending on the pt)
    • Age 14-15: Jointly develop a Transition Plan with youth and parents. During this time, providers should create a safe space within clinic visits for teens to start practicing self-management skills.
    • Age 16-17: Review and update Transition Plan, and prepare for adult care.
    • By age 18, youth understand and have experienced an adult model of care. Before actually transitioning, the teen and family can visit adult medicine practices, meet new providers, and decide who will be the best fit for their needs. Some may not be ready until closer to age 21.
  3. What are the key elements of transition? Six Core Elements of Transition have been described, include establishing a policy, tracking progress, administering transition readiness assessments, planning for adult care, transferring, and integrating into an adult practice. Using these elements helps start the conversation with families early and provide a standardized process.
  4. What resources are there to help with this process? GotTransition.org provides customizable forms on their website, which can be used to create many of the important documents needed in transition. For medically complex adolescent patients who see multiple specialist providers for their care, this process will probably be more complicated, so it is encouraged that you start this process early! Locally, the UW Medicine Transitions Clinic can be a valuable resource for 18-24 year old patients with complex medical needs, as well as the Center for Children with Special Needs which supports families with adolescent care transitions.

TOW #43: Seasonal allergies

May is designated National Asthma and Allergy Awareness Month. The pollen currently covering my car is definitely one indication it’s spring and allergy season! Indeed, many among us are suffering from the season’s blooms.

Materials for this week:

Here are take-home points about evaluating stuffy nose/allergic rhinitis:

  1. How many people are affected by allergic rhinitis? Allergic rhinitis (AR) is considered among the most common chronic diseases in children, with a prevalence of up to 40%. As with other atopic disease, prevalence of AR has increased rapidly in the past 30 years. Children who have one form of atopy (allergic rhinitis, asthma, eczema) have a 3x greater risk of developing a second. The mean age of onset in one study was 10 years; by 6 years, 42% had been diagnosed with AR.
  2. What is the clinical definition or AR? Rhinitis is defined as “Inflammation of the membrane lining the nose, characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or postnasal drainage.” AR is a hypersensitivity reaction to allergens due to IgE. Intermittent allergic rhinitis involves symptoms <4 days per week or for <4 weeks. Persistent symptoms occur >4 days per week for >4 weeks. It’s often tricky to evaluate relative to viral-induced symptoms, given there is so much frequency of both, but with AR, itching of nose and eyes is more prominent, rhinorrhea is clear.
  3. What do we see on physical exam? Nasal turbinates may appear edematous, with a pale to bluish hue. Cobblestoning from lymphoid hyperplasia may be seen on the posterior oropharynx. “Allergic shiners” are dark discolorations underneath the eyes due to venous engorgement and suborbital edema. Dennie-Morgan lines are folds under the eyes due to edema. The “allergic salute” is a transverse nasal crease in children who chronically push their palms upward under their noses (to wipe mucus)-(and they really happen – last year my daughter developed one of these!)
  4. What’s the appropriate work-up? You may decide to do skin testing to evaluate specific allergens and aid in environmental control strategies, such as for dust mites. Skin testing is preferred to blood testing, but is not 100% specific and requires clinical correlation with symptoms/triggers.
  5. How do we manage AR? Treatment options are allergen avoidance, pharmacotherapy, and immunotherapy (reserved for severe cases). Best medication class is intranasal steroids, which is approved for kids >2. Next best are non-sedating antihistamines (not as good at decreasing nasal congestion, specifically) or leukotriene receptor antagonists. Sometimes people develop tolerance to one group, so switching drugs can help. Decongestants are not recommended for young children due to side effects and rebound symptoms, and are only occasionally used in older children.