Pass Medicine 42

7/21/2019 Pass Medicine 42

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An 18 year old male presented to the Emergency Department complaining of blood in his urine for the last

day. He described it initially as few drops of dark blood at the end of micturition but has gradually

worsened such that at the time of admission he was passing large amounts of cola coloured urine. He also

complained of swollen ankles and puffy eyes developing over the last few hours and had been feeling

increasing lethargic and unwell over the last two days. When questioned specifically he denied the

presence of shortness of breath, chest pain, haemoptysis, previous haematuria or change in urine volume

and had otherwise been well in himself. He had no previous renal problems, though he recalled that his

brother had been prescribed a course of steroids when he was aged nine years old for leaky kidneys. Other

than a one week course of phenoxypenicillin 500mg QDS prescribed by his GP two weeks ago for tonsillitis

and a one week course of amoxicillin 500mg TDS prescribed 6 months ago for acute sinusitis he had no

drug history and no past medical history of note.

Examination revealed the presence of a young athletic male with a blood pressure of 162/84 mmHg, heart

rate of 96bpm, respiratory rate of 18/min, oxygen saturations of 95% on air and temperature of 37.1

Celsius. Examination of the cardiovascular system revealed the presence of normal heart sounds, a JVP of

3cm and the presence of bilateral pitting oedema of his ankles. Examination of his respiratory system was

unremarkable with no signs of respiratory distress. Examination of his gastrointestinal system was

unremarkable. Examination of his face revealed the presence of bilateral periorbial oedema; examination

of his ENT and neurological systems were both unremarkable.

Initial investigation revealed the following results:

Hb 13.2 g/dl

Platelets 428* 10 /l

WBC 14.2 * 10 /l

ESR 26 mm/hr

Na 138 mmol/l

K 5.2 mmol/l

Urea 6.4 mmol/l

Creatinine 77 µmol/l

CRP 18 mg/l

Bilirubin 18 µmol/l

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ALP 82 u/l

ALT 21 u/l

Protein 78 g/l

Albumin 39 g/l

CXR: normal appearance of heart and lung fields

ECG: sinus tachycardia 108bpm

Urinalysis: blood ++++ protein ++++, ketones +, negative all other parameters

Urine MCS: awaiting result

Blood MCS: awaiting result

What is the most likely diagnosis?

Rapidly progressive glomerulonephritis

Berger's nephropathy

Wegner's granulmatosis

Post streptococcal glomerulonephritis

Membraneous nephropathy

This gentleman has developed post streptococcal glomerulonephritis (PSGN), an immune mediated

reaction in response to the presence of specific strands of Streptococcus spp. The latent period is

classically one to two weeks post infection and presents with an acute glomerulonephritis characterised

by haematuria (with dark urine owing to the haemolysis of red blood cells that have penetrated the

glomerular basement membrane), proteinuria, oedema with or without oliguria. A key differential diagnosis

is Berger's nephropathy, the most common form of adult glomerulonephritis. This tends to present one to

two days post a non specific upper respiratory tract infection and is characterised predominantly by

haematuria, with an usually excellent prognosis. Rapidly progressive glomerulonephritis is associated witha rapid decline of renal function but may present with similar features to PSGN, whilst membraneous

nephropathy is characterised by a nephrotic syndrome.

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Post-streptococcal glomerulonephritis

Post-streptococcal glomerulonephritis typically occurs 7-14 days following a group A beta-haemolytic

Streptococcus infection (usually Streptococcus pyogenes). It is caused by immune complex (IgG, IgM and

C3) deposition in the glomeruli. Young children most commonly affected.

Features

general: headache, malaisehaematuria

nephritic syndrome

hypertension

low C3

raised ASO titre

Renal biopsy features

post-streptococcal glomerulonephritis causes acute, diffuse proliferative glomerulonephritis

endothelial proliferation with neutrophilselectron microscopy: subepithelial 'humps' caused by lumpy immune complex deposits

immunofluorescence: granular or 'starry sky' appearance

Carries a good prognosis

(http://d32xxyeh8kfs8k.cloudfront.net/images_Passmedicine/usb072b.jpg)

© Image used on license from

PathoPic (http://d32xxyeh8kfs8k.cloudfront.net/images_Passmedicine/usb072b.jpg)

Proliferation of endothelium and mesangium with recruitment of

http://d32xxyeh8kfs8k.cloudfront.net/images_Passmedicine/usb072b.jpg




neutrophils. Tubules are normal




Subepithelial humps on the outside of the basal membrane




Electron microscopy. Numerous neutrophils (blue arrows) and

subepithelial humps (red arrows)

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