An 11-day-old baby girl presents to her pediatrician with new
onset jaundice. She is a full term infant born via a spontaneous
vaginal delivery without any complications during the
pregnancy or delivery. Her total bilirubin at the time of
discharge from the full term nursery on day of life 2 was
6.5 mg/dL. The mother’s blood type is Oþ, and the infant’s
blood type is Bþ with the direct antibody test negative.
Maternal hepatitis B surface antigen is negative. She is breastfeeding every 2–3 hours with good weight gain.
She is afebrile without acholic stools, vomiting, irritability,
or bleeding. There is no family history of hyperbilirubinemia,
Alagille syndrome, or alpha-1-antirypsin deficiency.
Her vital signs are stable. Physical examination is normal
except for icterus. There is no dysmorphic facies, nystagmus,
heart murmur, or hepatosplenomegaly. Stool is yellow in
color.
Laboratory evaluation performed during the clinic visit shows a total bilirubin 8.5 mg/dL, conjugated bilirubin 3.5 mg/dL, aspartate aminotransferase 20 IU/L, alanine aminotransferase 46 IU/L, gamma-glutamyl transpeptidase (GGT) 288 IU/L, and alkaline phosphatase 163 IU/L.
A complete blood count (CBC) shows white blood cell count
12.3 x 109/L, hemoglobin 17.7 g/dL, and platelets 248 x 109/L
with a differential of 26% segmented neutrophils, 58%
lymphocytes, 11% monocytes, and 5% eosinophils. Newborn
screening result is normal. The prothrombin time is 9.3 seconds.
A liver ultrasound shows a normal appearing liver without intrahepatic or extrahepatic biliary dilatation.
Further evaluation included an alpha-1-antirypsin phenotype,
and toxoplasma IgM, which were normal. Urine was
negative for cytomegalovirus. TSH is normal.
Further evaluation reveals the cause of her conjugated
hyperbilirubinemia.
What do you think that investigation?
what was the diagnosis?
Answer
A catheterized urine sample was positive for nitrites and leukocyte esterase and showed 25–50 white blood cells and 5–50 bacteria/ high powered field.
A urine culture subsequently grew >100,000 colonies/ mL of Escherichia coli. The infant was treated with 14 days of amoxicillin clavulanate. On day 5 of antibiotic treatment, the infant’s conjugated bilirubin decreased to 1.3 mg/dL, and two weeks after completing the course of antibiotics, the total bilirubin was 1.0 mg/dL and conjugated bilirubin was 0.4 mg/dL. As part of the evaluation for her urinary tract infection, she underwent a voiding
cystourethrogram and renal ultrasound that showed bilateral
grade 3 vesicoureteral reflux and bilateral Society for
Fetal Urology (SFU) grade 2 hydronephrosis, respectively
Lessons for the Clinician
• For neonates with jaundice, check a serum level of
conjugated bilirubin with the total bilirubin.
• A direct bilirubin may overestimate the conjugated
bilirubin.
• When evaluating a well-appearing infant with conjugated
hyperbilirubinemia, include a urinalysis and urine
culture.
• For full term, well-appearing infants<8 weeks of age with
jaundice, the risk of having a UTI is 5.5–7.5%. In these
cases, the hyperbilirubinemia will resolve with treatment
of the UTI.
Answer
A catheterized urine sample was positive for nitrites and leukocyte esterase and showed 25–50 white blood cells and 5–50 bacteria/ high powered field.
A urine culture subsequently grew >100,000 colonies/ mL of Escherichia coli. The infant was treated with 14 days of amoxicillin clavulanate. On day 5 of antibiotic treatment, the infant’s conjugated bilirubin decreased to 1.3 mg/dL, and two weeks after completing the course of antibiotics, the total bilirubin was 1.0 mg/dL and conjugated bilirubin was 0.4 mg/dL. As part of the evaluation for her urinary tract infection, she underwent a voiding
cystourethrogram and renal ultrasound that showed bilateral
grade 3 vesicoureteral reflux and bilateral Society for
Fetal Urology (SFU) grade 2 hydronephrosis, respectively
Lessons for the Clinician
• For neonates with jaundice, check a serum level of
conjugated bilirubin with the total bilirubin.
• A direct bilirubin may overestimate the conjugated
bilirubin.
• When evaluating a well-appearing infant with conjugated
hyperbilirubinemia, include a urinalysis and urine
culture.
• For full term, well-appearing infants<8 weeks of age with
jaundice, the risk of having a UTI is 5.5–7.5%. In these
cases, the hyperbilirubinemia will resolve with treatment
of the UTI.
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