Differential Diagnoses

Differential Diagnosis 1

ACUTE PYELONEPHRITIS

Pathogenesis:

  • Acute pyelonephritis is an infection found in the upper urinary tracts.
  • E. coli, Proteus or Pseudomonas are the most common microorganisms.
  • The microorganisms move up along the ureters and can enter the bloodstream.
  • The inflammatory process is initiated affecting the renal pelvis causing renal edema and purulent urine.

Predisposing factors:

  • Kidney Stones
  • Instrumentation (indwelling urinary catheters)
  • Female sexual trauma

Clinical Manifestations:

  • Fever
  • Chills
  • Flank/groin pain
  • Urinary frequency/dysuria
  • Malaise

Rationale:

Mrs. C. M.’s presentation included urinary frequency, dysuria, and malaise. Mrs. C. M. had a urinary catheter during surgery, increasing her risk for acute pyelonephritis. Although Mrs. C. M. presented with malaise, it is usually a non-specific symptom in acute pyelonephritis in older adults.

Because Mrs. C. M. did not present with flank pain or a fever, we were able to rule out this diagnosis. In acute cystitis, which is a lower UTI, manifestations are usually localized.  Individuals with acute cystitis experience suprapubic and low back pain.

In acute pyelonephritis, which is an upper urinary tract infection, systemic manifestations are likely that include fever and chills.  With pyelonephritis, flank or groin pain is observed (due to injury to the kidneys) instead of suprapubic and low back pain. 

Further testing including urinalysis and urine culture can be taken for confirmation or diagnosis of UTI, and for subsequent treatment with antibiotics.

The overall presentation of Mrs. C. M. allows us to conclude that acute pyelonephritis is not her diagnosis.

Figure 1. Pyelonephritis. (Saunders, 2012)

Reference:

McCance, K. L., Huether, S. E., Brashers, V. L., Rote, N. S., & McCance, K. L. (2019). Pathophysiology: the biologic basis for disease in adults and children. (pp.1351-1352), St. Louis, MO: Elsevier.

 

Differential Diagnosis 2

BLADDER CANCER – UROTHELIAL CARCINOMA

Pathogenesis:

  • Most common bladder cancer
  • Involves inner lining of bladder
  • Tumors usually composed of uroepithelial cells
  • Papillary growth like patterns
  • Metastasis to lymph nodes, liver, bone, lungs, and adrenal glands

Figure 2. Carcinoma of the Bladder (Mosby, 1990)

Predisposing Factors:

  • Men 60 years or older
  • Smoking
  • Arsenic in drinking water
  • Tumor-suppressor gene TP53 mutations

Clinical Manifestations:

  • Hematuria
  • Daytime voiding frequency
  • Nocturia
  • Urgency incontinence
  • Flank pain

Rationale:

Mrs. C. M. was recently diagnosed with Stage IIA Right Breast Cancer with lymph node involvement that could have potentially spread to her bladder. Mrs. C. M. is experiencing frequent urination which could be a possible sign of bladder cancer.

An additional reason for choosing this differential is that Mrs. C. M. recently quit smoking. Smoking is a risk factor for bladder cancer. Further investigation should be done to see if Mrs. C.M. has arsenic in her drinking water.

Collectively, these findings have led us to the potential diagnosis of urothelial carcinoma. However, because Mrs. C.M. does not have hematuria, flank pain, or urge incontinence, we were able to rule out this diagnosis.

Reference:

McCance, K. L., Huether, S. E., Brashers, V. L., Rote, N. S., & McCance, K. L. (2019). Pathophysiology: the biologic basis for disease in adults and children. (pp.1348-1349), St. Louis, MO: Elsevier.

 

Differential Diagnosis 3

PELVIC INFLAMMATORY DISEASE (PID)

Pathogenesis:

  • Acute infectious inflammatory process
  • Involves any organ in the upper genital tract (uterus, fallopian tubes, ovaries, peritoneal cavity)
  • Microorganisms travel from the vagina through the upper genital tract
  • Chlamydia and gonorrhea are the most common cause

Figure 3. Salpingitis. (Mosby, 1996)

 

Predisposing factors:

  • Infection induces changes in columnar epithelium (lines the reproductive tract)
  • Inflammation occurs causing edema and potentially necrosis of specific area
  • Gonorrhea– attaches to lining and excretes toxic substances to mucosa increasing inflammation and edema
  • Chlamydia – enters tubal cells  –> replicates cell membrane bursts –> permanent scarring
  • Sexual activity

Clinical Manifestations:

  • Bilateral abdominal pain worsens with activity
  • Fever
  • Dysuria
  • Irregular bleeding
  • Vaginal discharge
  • May be asymptomatic

Rationale:

PID must be considered for Mrs. C. M. due to her symptoms of abdominal pain and painful urination. Pelvic inflammatory disease develops when the body’s defense mechanisms are altered, which results in disruption of normal flora, thus allowing pathogens to cause infection. Because Mrs. C. M. was recently hospitalized for surgery, her body’s defense mechanisms are low, potentially increasing her risk in developing PID. However, Mrs. C. M.’s recent hospital stay and the use of a urinary catheter is likely the culprit for her infection. It is a possibility that E. coli could have been introduced and caused disruption in her normal flora.

With PID, patients are likely to be infected with sexually transmitted microorganisms like chlamydia and gonorrhea instead of E. coli.

Clinical manifestations of PID are more likely to develop during or immediately after menstruation. This diagnosis may be ruled out based on the overall clinical manifestation of Mrs. C. M. She is 82 years old and is postmenopausal. Mrs. C. M. is not sexually active and denies any vaginal discharge. Mrs. C. M. is afebrile and fever is a manifestation of PID along with sudden, severe abdominal pain. For these reasons, this would be the least likely diagnosis for Mrs. C. M.

 

Reference:

McCance, K. L., Huether, S. E., Brashers, V. L., Rote, N. S., & McCance, K. L. (2019). Pathophysiology: the biologic basis for disease in adults and children. (pp. 813-815), St. Louis, MO: Elsevier.