From the Guidelines
The next best step in evaluating this patient is to consider a kidney ultrasound, as it is a non-invasive and useful initial imaging test to evaluate the kidneys and rule out any structural abnormalities or stones that might be contributing to the infection, as suggested by the inflammatory changes in the right kidney on CT scan 1. The patient's symptoms of intermittent hematuria, suprapubic pain, and low-grade fevers, along with the lack of response to ciprofloxacin, suggest a possible urinary tract infection that is not responding to first-line therapy.
- The CT scan has already shown inflammatory changes in the right kidney, which could indicate pyelonephritis or another renal pathology.
- A kidney ultrasound is a reasonable next step to further evaluate the kidneys and rule out any structural abnormalities or stones that might be contributing to the infection, as recommended by the ACR Appropriateness Criteria for acute pyelonephritis 1.
- Additionally, a urine culture with sensitivity testing should be considered to identify the specific pathogen and its antibiotic sensitivities, allowing for targeted therapy.
- While awaiting culture results, empiric treatment with a different antibiotic class may be reasonable, and hospitalization for IV antibiotics may be necessary if symptoms are severe.
- The patient's clinical presentation and lack of response to ciprofloxacin also raise concerns about antibiotic resistance, which has been increasing in urinary pathogens, particularly E. coli, the most common cause of urinary tract infections.
- According to the AUA/SUFU guideline, patients with microhematuria should be referred for nephrologic evaluation if medical renal disease is suspected, and risk-based urologic evaluation should still be performed 1.
- However, in this case, the patient's symptoms and imaging results suggest a possible urinary tract infection, and a kidney ultrasound is a more appropriate next step to evaluate the kidneys and rule out any structural abnormalities or stones.
From the Research
Evaluation of Patient with Intermittent Hematuria and Suprapubic Pain
The patient presents with intermittent hematuria, suprapubic pain, low-grade fevers, and mild weight loss, which have not responded to ciprofloxacin treatment. The CT scan shows inflammatory changes in the right kidney. Given these symptoms and findings, the next best step in evaluation is crucial for an accurate diagnosis.
Consideration of Genitourinary Tuberculosis
- The patient's symptoms, such as intermittent hematuria and suprapubic pain, along with the lack of response to antibiotic treatment, suggest the possibility of genitourinary tuberculosis (GUTB) 2, 3, 4.
- GUTB can present with nonspecific symptoms, making diagnosis challenging without a high index of suspicion.
- Imaging studies, including CT scans, can show inflammatory changes and other signs suggestive of GUTB, but are not definitive for diagnosis.
Diagnostic Approaches
- Urine PCR for Mycobacterium tuberculosis: This method has been shown to be sensitive and specific for the diagnosis of GUTB 2, 3, 4. It can provide a rapid diagnosis, which is crucial for initiating appropriate treatment.
- Kidney Biopsy: While a biopsy can provide a definitive diagnosis, it is an invasive procedure and may not be necessary if non-invasive tests like urine PCR are available and indicative of GUTB.
- Kidney Ultrasound: This can be useful for evaluating kidney morphology but is not specific for diagnosing GUTB.
- PCR for Neisseria gonorrhoeae and Chlamydia: Given the patient's reported lack of sexual activity, these tests may have lower priority in the diagnostic workup compared to evaluating for GUTB.
Recommendation
Based on the evidence, recommending C. Urine PCR for Mycobacterium tuberculosis as the next step seems appropriate. This approach aligns with the need for a rapid, sensitive, and specific diagnostic method for GUTB, given the patient's clinical presentation and the lack of response to initial antibiotic treatment 2, 3, 4.