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Case PresentationHarold B. Briosos

Junior Intern

St. Paul University PhilippinesSchool of Medicine

General Data Informant: Mother (90% reliability)

Name: JM

Age: 6 years old

Gender: Male

Date of Birth: August 2, 2008

Address: Brgy. Leonarda, Tuguegarao City, Cagayan

Date of Admission: July 3, 2015

Time of Admission: 7:00 am

Chief Complaint

Tea-colored urine

History of Present Illness

2 wks PTA

3 days PTA

3 hours PTA

(+) Pyoderma(-) Medications(-) Consultation

(+) Vomiting 2x, ½ cup/bout

(+) Epigastric Pain(+) Fever, 38ºc

(+) Dysuria➢ 🏥 UTI

💊 Paracetamol (13 mkd), Co-Amoxiclav

(40 mkd) Persistence of S/Sx(+) tea-colored urine(+) Periorbital edema

➢ (+) consultReferred, Admitted

Prenatal History

6xFeSO4FolateMVS

Natal History

28 year old Mother

G2P2(2002)

Cephalic

NSD

Assisted by a midwife

Birthing center

(-) Fetomaternal complications

Postnatal History

Vigorous

Good suck and cry

(+) Vit. K, Hep B, Crede’s Prophylaxis

(-) NBS

Birth weight: 4kg

Past Medical History

Good premorbid medical history

(-) Allergy: food or medication

Nutritional History

Exclusively breastfed for 7 months

Supplemental feeding at 7 months

No food preferences

Growth and Development

✔6m

✔7m ✔10m ✔8m ✔1y

✔5m

1st word• Mama, 6

months

Enters School• 5 years

Immunization History

1 BCG

3 Hep B, DPT, OPV

1 Measles

Family History

Arthritis

Unremarkable

Review of Systems

(-) Pruritus

(-) Myalgia

(-) Loss of Appetite

(-) Seizure, (-) Headache

(+) cough, (+) colds, (-) Difficulty of breathing, (-) Chest pain

(-) diarrhea, (-) constipation

Personal and Social History

Youngest child in a brood of 2

34 y/o mother, housewife

35 y/o father, laborer

1 storey, bungalow-type house

Water from local refilling station

Grade 1

Physical Examination

General Appearance: Awake, afebrile, not in cardiorespiratory

distress

Vital Signs: BP: 120/90 HR: 114 RR: 24 Temp: 36.9 BSA: 0.78

Blood Pressure

Anthropometric Measurements Height:

115cm

Weight: 19

BMI: 14.9 kg

Height: 115cm

Weight: 19

BMI: 14.9 kg

Height: 115cm

Weight: 19

BMI: 14.9 kg

Skin

(-) Pallor (+)Healing skin lesion

(-) Jaundice Right leg

(-) Rashes

(-) Cyanosis

Warm to touch

Good skin turgor

HEENT

(-) Lesions, (-) Lumps

Anicteric sclerae, Pinkish palpebral conjunctivae

(+) Periorbital edema

Visible cone of light, (-) discharges

(-) Alar flaring, (-) discharges, septum midline

(-) tonsillar hypertrophy, uvula midline

Mouth

(+) Dry lips (-) Ulcers Moist mucosa

Chest, Lungs and Heart

Symmetric chest expansion

(-) retractions, clear breath sounds

Adynamic precordium, PMI @ 4th ICS LMCL, tachycardic, regular rhythm, (-) Murmurs

Abdomen

Flat

Normoactive bowel sounds (8/min)

soft

(+) epigastric tenderness

(-) organomegaly

Genitalia

Grossly Male

Uncircumcised

Extremities

(-) gross deformities

(-) Edema

(+)skin lesions

Full, equal pulses

CRT <2sec

Neurologic Examination

MSE: Conscious, coherent, oriented to person, place and time.

Cerebellar: Able to do rapid alternating movement

Cranial Nerves

I: Able to smell

II: 2-3mm pupils, ERTL

II, IV, VI: EOM intact

V: (+) blink reflex

VII: Symmetric face

VIII: Good acuity to whispered voice

IX, X: (+) Gag reflex

XI: Shrugs shoulders

XII: Tongue at midline

Motor

Good muscle strength and tone allover

RU 5/5 LU 5/5

RL 5/5 LL 5/5

Sensory

Intact sensation to light touch and pinprick allover

RU 100%

LU 100%

RL 100%

LL 100%

Deep Tendon Reflexes

Biceps Triceps Patella Achilles

++ ++ ++ ++

Meningeal Signs

(-) Kernig’s sign

(-) Brudzinski’s sign

(-) Nuchal Rigidity

Impression

Acute Post-streptococcal Glomerulonephritis

Salient Features

Male

History of skin infection

Periorbital and facial edema

(+) tea-colored urine

(+) dysuria

(+) fever

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Differential Diagnoses

IgA Nephropathy

Berger’s Disease

common in older children

higher predilection to male than female 2:1

acute onset of fever and hematuria

30 - 50% of cases can have Hypertension and Edema of the hands and feet.

IgA Nephropathy

Rule In Rule Out

Common in males

(+) Hematuria

(+) Hypertension

(+) Fever

(-) Recurrent episodes of gross hematuria

(-) Pain in the flank

Membranoproliferative Glomerulonephritis

Mesangiocapillary glomerulonephritis

Most commonly occurs in children or young adults

Patients present with equal proportions of nephrotic and acute nephritic syndrome, or persistent asymptomatic microscopic hematuria and proteinuria

Membranoproliferative Glomerulonephritis

Rule In Rule Out

HematuriaHypertension

Onset: 2nd decade of life

Recurrent episodes of gross hematuria- usually assoc. with upper respiratory tract infections.

Henoch-Schönlein Purpura Nephritis

Most common small vessel vasculitis in childhood.

Characterized by purpuric rash, arthritis and abdominal pain.

Henoch-Schönlein Purpura Nephritis

Rule In Rule OutHematuria(+) abdominal pain

(-) Purpuric rashes(-) Arthritis(+) Hypertension(-) Proteinuria

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Course in the Ward

Day of Admission

Problems Assessment Intervention

BP: 120/90(+) Periorbital edemaWeight: 18kg

T/C Acute post-streptococcal glomerulonephritis

• D5 0.3 NaCl KVO• PenG 100,000 units mkDay• Furosemide 1 mkdose • Paracetamol 10 mkdose• Limit OFI 310cc/shift• Weigh pt. daily ODBB

Diagnostics:• CBC, UA w/ RBC

morphology, SE, BUN/Crea, ASO/ESR, C3, Lipid profile

Problems

Assesment Intervention

Hours after admission

BP: 110/70UO: 1cc/kg

T/C Acute post-streptococcal glomerulonephritis

• Furosemide 20mg/IV• BP monitoring• Strict I&O monitoring

Re-assessment

Re-assessment

Problems Assesment Intervention

Hours after admission

BP: 120/80CR: 70(+) Periorbital edema

• Furosemide 1mkdose• repeat BP after 30

minutes• Strict I&O monitoring

Re-assessment

Problems Assesment Intervention

Hours after admission

BP: 100/70CR: 70UO: 1cc/kg(+) Periorbital edema

• Furosemide maintained at 1mkdose q 6

• Strict I&O monitoring• Continue meds

Laboratory Findings

Serum Electrolytes Reference Range

Sodium 146.7 135-145

Potassium 3.90 3.5-5.4

Chloride 113.7 96-110

WBC 9.5 4.5-11.0

Laboratory Results

Urinalysis

Color straw

Transparency Clear

Specific Gravity 1.015

Albumin, sugar, ketones, bilirubin, urobilinogen, nitrite, leukocytes

(-)

Blood (+)

Leukocytes 1-3

Erythrocytes 8-10

Laboratory Findings

Complete Blood Count Reference Range

Hemoglobin 106 135-180

Hematocrit 0.32 0.40-0.54

Platelet count 412 150-400

WBC 9.5 4.5-11.0

Neutrophils 44.7 35-65

Lymphocytes 38.1 20-40

Laboratory Findings

Clinical Chemistry

Range

Urea 2.31 2.5-7.10

Creatinine 43.3 53-115

Total Protein 77 63-82

Albumin 36 35-50

Globulin 41 23-35

A/G Ratio .9 1.5-2.5

Hematology Result

ESR 80mm/hr

0-10

Serology Result

ASO (+) 400

First Hospital Day

BP: 100/70CR: 82RR: 24T: 36.8UO: 2 cc/kgWeight: 17kg

(-) Abd pain, (-) Headache(-) Nape pain, (-) pallor(-) no jaundice, (-) edema

AGN • Hook to heplock• decrease

furosemide 1mkdose q8

• Continue meds and management

• Strict I&O monitoring

• Limit OFI to 500cc/day

Laboratory Findings

Clinical Chemistry Normal

RangeCholesterol 4.2 mmol/L 0-5.17Triglycerides 1.27 mmol/L 0-1.69Direct HDLC .70 mmol/L 0-1.60LDL 2.92 mmol/L 0-3.35

2nd Hospital Day

Problem Assessment

Intervention

BP: 100/70CR: 78RR: 24Wt: 17UO: 2cc/kg(-) Headache, (-) Vomiting(-) Fever, (-) Epigastric Pain(-) Pallor, (-) edema

AGN • Strict I&O monitoring

• Furosemide IV shifted to oral

• PenG -> (50) Amoxicillin TID

Laboratory Findings

Clinical Chemistry

Normal Range

C3 13.8 mg/dL 90-180

3rd Hospital Day

Problem Assessment

Intervention

BP: 90/60UO: 2.5cc/kg/hrWt: 17kg(-) Headache(-) Vomiting(-) Fever(-) Epigastric Pain(-) Pallor(-) Periorbital Edema

AGN • MGH

Home Meds:• Amoxicillin 50 mkD TID x 8

days more• Multivitamins syrup, 5ml OD• Ascorbic Acid syrup, 5ml OD• Follow-up after 3 days with UA

with SG

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Case DiscussionAcute Poststreptococcal Glomerulonephritis

Acute Poststreptococcal Glomerulonephritis (APSGN)

Results from antecedent infection of nephritogenic strains of Group A ß-hemolytic streptococci of the:

a. Skin (Impetigo) - M-types: 2, 49, 55, 57, and 60

b. Throat (pharyngitis) – M-type: 1, 3, 4, 12, 18, 25, and 49

Susceptibility

Children 2-12 years old

Male

Familial predisposition

Disease Course

1-2 weeks after streptococcal pharyngitis

3-6 weeks after impetigo

Pathophysiology

Pathophysiology

Clinical Manifestations

• Hematuria (gross or microscopic) • Other cardinal features of glomerular

injury Proteinuria Hypertension Edema Oliguria Renal insufficiency

Laboratory Workups

URINE ANALYSIS

Dysmorphic or crenated red blood cells and red blood cell casts.

Proteinuria, usually moderate, reaches the nephrotic range in 5 to 10% of patients with APSGN.

Leukocyte, hyaline, and granular casts are also frequently seen.

Transient elevation of blood urea nitrogen and serum creatinine.

Laboratory Workups

Antibody Titers

Recent streptococcal infection.

Increased titers of antibodies.

Serum levels of IgG and IgM are elevated in 90% of patients.

Management

Supportive measures

Bed rest and limitation of physical activities

Dietary Na restriction

Control of dietary protein and potassium.

Fluids are limited

All fluids should be given orally when tolerated.

Drug Therapy

• Loop diuretics• Sublingual and oral calcium channel

blockers (nifedipine)• ACE Inhibitors such as captopril• Penicillin

Complications

Hypertensive encephalopathy

Intracranial bleeding

Acute renal failure

Prognosis

Complete recovery in 95% of patients

Recurrences are rare

Prevention

Pneumococcal conjugate vaccine children younger than 5 years old, all

adults 65 years or older.

Pneumococcal polysaccharide vaccine Adults 65 years or older

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