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Hemolytic Uremic Syndrome (HUS), an endemic disease in Argentina, is characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury. Although most cases have been associated with gastrointestinal infections caused by shiga toxin-producing escherichia coli (STEC), there are few cases reports of HUS associated with urinary infection (IU) by E.Coli.
The objective of this study is to present a case report of HUS secondary to urinary infection by STEC.
Clinical case:
A 3-year-old girl presented with fever, vomiting and jaundice of 24 hours of evolution. The laboratory showed an increase in creatinine of 1.5mg/dl - glomerular filtration rate (GFR) of 30ml/min/1.73m2, microangiopathic hemolytic anemia, plateletopenia (30,000/L) along with leukocytosis of 16,700/MM, elevated LDH and decreased haptoglobin (< 5mg/dl). Urinary sediment with proteinuria, macrohematuria (>40 red blood cells/field), covered field leukocytes, positive leukocyte esterase. She received a transfusion of red blood cells and was initially rehydrated with saline solution, subsequently maintaining an adequate diuretic rhythm. Renovesical ultrasound showed both kidneys slightly enlarged, with increased parenchymal echogenicity and decreased corticomedullary ratio, without dilation of the urinary tract. She had a positive urine culture for E. coli > 100,000 CFU with negative blood cultures and, although she did not present diarrhea, given the HUS condition, an etiological and verotoxin search was carried out in fecal matter, which turned out to be negative. Anti-lipopolysaccharide (LPS) antibodies were performed, with IgG being positive for strain 0145. She completed antibiotic treatment for UI with cephalexin and progressed favorably with a GFR at discharge of 115ml/min/1.73m2 and a blood count within normal parameters.
Discussion
It is more common for E. Coli to cause UI than intestinal infections. However, the generation of HUS secondary to UI is uncommon and rarely presents Shiga Toxin rescue. Regardless of the starting point, the treatment provided is supportive and may require dialysis in the most severe cases. The use of antibiotics is not recommended for the treatment of diarrhea due to E. coli since it can induce greater release of toxins. However, if HUS is caused by UI due to STEC, antibiotic therapy is indicated in order to prevent kidney damage, which could have a negative impact on the patient's evolution. There are articles that report HUS due to UI due to STEC frequently associated with more severe kidney injury. Fortunately, our patient had a favorable evolution without requiring dialysis.
HUS secondary to UI due to STEC has been described but is rare, and although this was not the case in our patient, it usually has a worse outcome.