Ruling Out Active Infection Before Starting Short-Course Steroids
Based on the available information (elevated WBC count of 14,000 without fever and normal urinalysis), active infection cannot be definitively ruled out, and additional diagnostic evaluation is recommended before starting steroids in a patient with prior UTI history.
Assessment of Current Clinical Picture
The clinical scenario presents several important factors to consider:
- 21-year-old male weighing 50 kg
- History of previous UTI
- Current WBC count of 14,000 (leukocytosis)
- No fever
- Normal urinalysis (URM normal)
- Plan to start short course of steroids (20 mg for 5 days)
Significance of Leukocytosis Without Fever
Leukocytosis (WBC count of 14,000) without fever is concerning and requires careful evaluation:
- Elevated WBC count is a significant indicator of potential underlying infection even in the absence of fever 1
- Leukocytosis with high percentage of neutrophils or left shift indicates high probability of bacterial infection, even without fever 1
Diagnostic Approach Before Starting Steroids
Urinalysis and Urine Culture Interpretation
- Normal urinalysis (negative for leukocyte esterase and nitrite) has good negative predictive value for ruling out UTI 1, 2
- However, in patients with prior UTI history, a urine culture should be performed before starting steroids 1
- For patients with suspected infection, both urinalysis and urine culture should be obtained 1
Additional Recommended Tests
Before starting steroids, the following should be performed:
- Complete blood count with differential to evaluate the nature of leukocytosis (neutrophilic vs. lymphocytic) 1
- Urine culture to definitively rule out UTI, especially with history of prior UTI 1
- Blood cultures if systemic infection is suspected 1
- Clinical evaluation for other sources of infection (respiratory, skin, etc.)
Risk Assessment for Steroid Therapy
Steroid-Related Infection Risks
The FDA label for oral steroids highlights important warnings 3:
- Steroids may mask signs of infection
- New infections may appear during steroid use
- Decreased resistance and inability to localize infection may occur
- Particular caution needed in patients with history of infection
Special Considerations for This Patient
- Young male with leukocytosis (14,000) without fever
- Prior history of UTI increases risk of recurrence
- Short course of steroids (20mg for 5 days) carries less risk than longer courses
- Normal urinalysis is reassuring but not definitive without culture
Clinical Decision Algorithm
If urgent need for steroids (e.g., inflammatory condition requiring immediate treatment):
- Obtain urine culture before starting steroids
- Start empiric antibiotic coverage if high suspicion of infection
- Begin steroids with close monitoring
If steroids can be delayed:
- Complete infection workup including urine culture
- Evaluate other potential sources of leukocytosis
- Wait for culture results before starting steroids (typically 24-48 hours)
- Reassess WBC count after 24-48 hours
If steroids must be started immediately:
- Consider prophylactic antibiotic coverage
- Monitor closely for signs of infection
- Be prepared to increase antibiotic coverage if infection manifests
Conclusion
The elevated WBC count of 14,000 without fever represents a significant concern for potential underlying infection despite normal urinalysis. While normal urinalysis reduces the likelihood of UTI, it does not definitively rule out infection, especially with prior UTI history.
Important caveats:
- Steroids can mask infection signs and decrease host resistance 3
- Disseminated infections like strongyloidiasis can be fatal in patients on steroids 4
- Leukocytosis without fever can still indicate significant bacterial infection 1
The safest approach is to obtain a urine culture and evaluate for other sources of infection before starting steroids, even for a short course.