Struvite stones causing recurrent pain in a child with cerebral palsy: a lesson for a pragmatic approach to pain in children with cerebral palsy and cognitive impairment.

Abstract

Background Children with severe cognitive impairments (CI) from any cause, such as cerebral palsy (CP), dysmorphic or chromosomal syndromes, traumatic brain injury, neurodegenerative disorders, and epileptic syndromes, experience pain more frequently than healthy peers. Although it is a common problem, pain is many times unrecognized because these patients are often unable to self- verbalize it or exhibit uncommon behaviors when they experience it, leading to a delay in the recognition and management of pain by the physicians. Untreated chronic or recurrent pain profoundly affects the quality of life of these children and interferes with their performance and adaptive function. Recognition, measurement, and treatment of pain in this population is challenging, and a clinical diagnosis of urinary tract infection or lithiasis may not be immediate. Case presentation: We report the case of an eight-year-old child with cerebral palsy who was admitted for recurrent abdominal pain lasting for one month. While blood laboratory tests were all in the normal range, the diaper examination revealed multiple stones. Urine culture tested positive for Providencia stuartii, a Gram-negative bacteria, and an antibiotic treatment with ceftibuten was started for two weeks. The patient fully recovered in three days without any recurrence. Conclusions urine analysis, to detect an infection, and renal and bladder US, to rule out stones, should be systematically considered in patients with cognitive impairment with unexplained pain. In a pragmatic, concise approach, the basic principles of diagnosis and treatment of pain in children with cognitive impairment are reviewed.