Cases corner – 44 years old with recurrent infections
14th August 2019
Jane is 44-year-old women who attends with a 1-week history of dysuria. This is her fourth presentation in the last 8 months with lower urinary tracts symptoms. With each episode a urine sample was sent for microscopy and culture – which came back positive for a simple bacterial infection. She has previously completed three courses of antibiotics which resolved her symptoms. Subsequent MSUs have been negative in between episodes. She is afebrile and does not have any systemic symptoms. She is asymptomatic between episodes. You organise a urine dip which is positive for nitrites only. Examination and observations are unremarkable. There is no past medical history, drug history or family history of note.
What should you do next?
- Send the urine to the lab and prescribe a short course of antibiotics for a lower urinary tract infection
- Send the urine to the lab and book a follow-up with the patient to treat following review of results
- Send the urine to the lab, prescribe antibiotics and organise urgent bloods including a full blood count
- Send the urine to the lab, prescribe antibiotics and refer the patient under a 2-week-wait haematological referral
NICE references the European Association of Urology Guidelines on Urological Infections for the definition of recurrent urinary tract infections in adults. This is defined as repeated UTI’s with a frequency of 2 or more UTIs in the preceding 6 months or, 3 or more UTIs in the preceding 12 months. For this patient it is clear she meets the definition of recurrent UTIs. The next steps of management are vast. All would agree that she needs further investigations. Had she been over 60, she would have qualified for a non-urgent referral for bladder cancer. However, at 44 Jane is at a high risk of a haematological malignancy.
Suggesting the patient may be at risk of a haematological malignancy, like leukaemia, may sound odd in the first instance. However, recurrent infections, regardless of the site of the infection, are a common feature of Leukaemia. Patients should be investigated to rule out a haematological malignancy. Nationally, NICE recommends conducting an urgent full blood count (within 48 hours) to assess for leukaemia. Across London, where the threshold for investigation is lower, doctors are advised to refer the patient along a 2-week-wait haemaltogical pathway for further investigations.