Psgn _acute Glomerulonephritis

8/2/2019 Psgn _acute Glomerulonephritis

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ACUTE

GLOMERULONEPHRITIS

CASE PRESENTATION


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General Objective

To present a case of Acute Glomerulonephritis


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Specific Objectives

To discuss Acute Glomerulonephritis as todefinition, etiology, epidemiology, andpathophysiology

To generate appropriate differential diagnosis To recognize the typical clinical manifestations

To provide the proper management and

prognosis of the disease


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GENERAL DATA

J.R.N., 5 years old, EDS

Roman Catholic

Born on June 18, 2002

1st time admission on March 1, 2008


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CHIEF COMPLAINT:

abdominal distention


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History of Present Illness

1 month PTA pyodermal lesions on both legs

no asstd signs & symptoms

(-) consult

self-medicated with Penicillin

10 days PTA warm, erythematous, pruritic lesionswere noted on the left leg

No asstd signs & symptoms

(-) consultliniments

9 days PTA lesions spread to trunk and extremities

(+) abdominal painno consult done nor medications

taken


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8 days PTA (+) facial and periorbitaledema

(-) changes in urine colorand frequency

self-medicated withDicycloverine 5ml q6

hours x 2 days7 days PTA (+)Facial and periorbital edema -

receding

5 days PTA edema persisted now associated

with abdominal distentionNo consult nor medications


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1 day PTA (+) abdominal distention, puffy eyelids andfacial edema

(+) bipedal edema

(-) change in color of the urine

Consult: Fort Magsaysay Station Hospital(-) laboratory examinationsDx: Allergic Reaction

Meds:Chlorphenamine maleate2mg/5ml, 5ml TID

(+) abdominal pain

Few hours PTA persistence of symptomsconsult: private physician

Dx: Acute Glomerulonephritis

Urinalysis

transferred to our institution

admitted

Color AmberTransparency turbid

Reaction 5.0Sp. Gravity 1.015Sugar -Protein +4RBC plentyPus cells 80-90


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PRENATAL Hx:

Cognizant at 1 month AOG

regular PNCU at public hospital in CabanatuanCity

regular intake of multivitamins and ferroussulfate

denies any exposure to radiation, infections,

communicable diseases, intake of teratogenicdrugs


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NATAL Hx:

born to a 29 y/o G5P5 (5005), FT

delivered via NSD at Fort Magsaysay

BW of 2.7kg

good cry and activity

no fetomaternal complications noted


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FEEDING Hx:

Birth 1 mos old pure breastfeeding

1mos 6 mos - BONNA

6mos 16 mos pure breastfeeding

16mos - present Bear brand

weaning - 7 months

solid foods at 10 months

At present - 1 cup of rice per meal and

prefers to eat hotdog, salted fish. Drinks 1-2 glasses of milk formula (Bearbrand) perday


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IMMUNIZATION

BCG

OPV3

DPT3 Measles

*local health center


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GROWTH AND DEVELOPMENT

Gross motor

- Can ride a tricycle, jump

Fine motor

- Imitate a circle and draw lines, can write name Language

- Can count 1-10, can identify colors

Personal/social

- Plays interactive games, washes and drieshand


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PAST MEDICAL Hx

8 mos old admitted for 5 days at PJN(Cabanatuan City) due to Bronchopnuemonia

2-3 episodes of cough and colds a year lasting

for 5-7 days

no allergy to foods and drugs

no childhood diseases noted


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FAMILY Hx:

Father- 40 y/o, soldier Mother- 35 y/o, housewife

Siblings

1- 16 y/o, female 2- 14y/o, female

3- 11y/o, female 4- 8y/o, male5- index patient 6- 4y/o, male

(+) DM and (+) HPN maternal grandfather

(+) bladder stone maternal grandfather (+) BA maternal uncle

(+) kidney diseases maternal cousins

(-) malignancy, PTB


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PERSONAL AND SOCIAL Hx:

5th of 6 siblings

lives with 8 other household members

bungalow type of house with 3 BR and 2 CR

Mother primary caregiver

Water source - deep well

Garbage - disposed properly


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REVIEW OF SYSTEMS:

Constitutional: (-) fever, (-) weakness

HEENT: (-) blurring of vision, (-) sorethroat, (-) nasal obstruction

Respiratory: (-) hemoptysis, (-) shortness

of breath GIT: (-) vomiting, (-) constipation,

(-) diarrhea

GUT: (-) dysuria, (-) urethral discharge NS: (-) headache, (-) LOC, (-) numbness

Extremities: (-) stiffness of joints


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PHYSICAL EXAMINATION:

General Survey: conscious, coherent, ambulatory,afebrile, not in distress

Vital Signs:

BP- 150/100 CR- 98 RR- 32 T- 36.80C

Anthropometrics:

Wt 20 kg (p75) IBW 18 kg

Ht 106 cm (p25) IBH 112 cmG - 111% S - 94.6% W - 114.3%


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Skin: warm, moist, good skin turgor and elasticity,CRT < 2sec

HEENT: pink palpebral conjunctivae, anictericsclera, intact tympanic membrane AU, no naso-aural discharge, no tonsillopharyngeal

congestion, (+) facial edema, (+) puffy eyelids

Neck: supple, no palpable lymph nodes


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Chest/Lungs: symmetrical chest expansion, clear breath

sounds, no retractions, good air entryHeart: adynamic precordium, normal rate, regular

rhythm, no murmur

Abdomen: distended, slit-like umbilicus, AC = 52cm,

soft, non-tender, no organomegaly, (-) fluid waveExtremities: no gross deformities, full and equal pulses,

bipedal edema, (+) healed pyodermal lesions, nocyanosis


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ASSESSMENT:

Acute Glomerulonephritis prob Post

Streptococcal Glomerulonephritis


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Salient Features:

5 years old, male

History of pyodermal lesions

PE: Abdominal pain and distention

Edema periorbital, bipedal

Slit like umbilicus Hypertension


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Laboratory:- Urinalysis

Hematuria (microscopic)

Proteinuria Pyuria


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COURSE IN THE WARDS:

Upon admission

Laboratory examinations Urinalysis

C3, ASO CBC

Serum electrolytes BUN, Crea TPAG KUB UTZ

Therapeutics Furosemide 1mkdose

Pen G 100,000 u/kg/day Nifedipine 5mg prn for BP >120/80

Color: dark yellow

Transparency : turbidReaction: 6.0Sp. Gravity: 1.010Sugar: -Protein: +3RBC: 20-30Pus cells: 40-50

ASO negative

Hgb 110Hct 0.33RBC 4.31WBC 19.9Plt count 313S 0.58L 0.28E 0.14

Na 142.9K 5.14

Cl

116.9Crea 40.3

TP 55.5Albumin 26.4Globulin 27.1


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1st hospital day

S > with hypertensive episodesabdominal pain

O > conscious, ambulatory

BP 150-120/80-90 CR 80-88 bpm RR 20

cpm Temp 36.5-37.10Cslit like umbilicus, AC = 52cm

bipedal edema

facial edema

A > AGN prob PSGN

P > HL

Meds: Pen G 100,000u/kg/day

Furosemide q12H


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2nd hospital day

S/O > (+) facial and bipedal edema - receding

(-) abdominal pain

BP 110-130/70-100

AC = 51 cm (52cm)Adequate urine output (1.6 cc/kg/hr)

A > AGN prob PSGN

P > Oral fluid intake limited to 190ml qshift

Furosemide 1mkdose q12 hours

Pen G continued


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3rd hospital day

S/O > (+) episodes of hypertension

(-) facial edema

(-) bipedal edema

AC = 46cm (51)

A > AGN prob PSGN

P > Nifedipine was discontinued

Furosemide q8H shifted to q6Hwith BP precautions


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5th hospital day

S/O > (-) edema

(-) hypertensive episodes

adequate urine output

A > PSGNP > For repeat urinalysis

Furosemide to q8hrs

Pen G D5

Color AmberTransparency turbid

Reaction 6.0Sp. Gravity 1.015

Sugar -Protein -

RBC TNTCPus cells 0-2

C3 430mg/L


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6th hospital day

S/O > (-) hypertensive episodes

(-) edema

(-) abdominal pain

A > PSGNP > Pen G IV shifted to Sumapen

250mg/5ml, 6.5 ml q6H

referral to Pedia Nephrologist

(Furosemide q8H then taper)


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9th hospital day

S/O > AC = 45cm

wt = 16.2 kg

adequate urine output

stable vital signs

A > PSGNP > Furosemide discontinued

Home meds:

Sumapen 250mg/5ml,6.5 ml q6H x 4 days

MV syrup, 1 tsp OD

KUB UTZ (3/12/08)


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Final Diagnosis:

Post Streptococcal Glomerulonephritis


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DISCUSSION


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ACUTE GLOMERULONEPHRITIS

- Usually signifies an inflammatory processcausing renal dysfunction over days to weeks

that may or may not resolve

Currents, 2003


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Sudden onset of gross hematuria, edema,hypertension, and renal insufficiency

One of the most common glomerular causes of

gross hematuria in children

Nelsons, 17th ed


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Etiology

Streptococcal pharyngitis (serotype 12) coldweather months

Streptococcal skin infections or pyoderma

(serotype 49) warm weather months

Textbook of Pediatrics and Child Health, 4th ed


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Epidemiology

Post -infectious type most common

most common in males (1.7 -2:1) ages 6 to 10 butcan occur at any age

Handbook of Diseases, Copyright 2003

Pathophysiology


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Pathophysiology

pyodermal lesions

Ag-Ab complex

Ag-Ab complement complex

Autoimmune/inflam rxn in glomerulus

Na, water balance

ECF expansion

DIURETIC PHASE

CONVALESCENT PHASE

Edema, HPN, CHF

decrease C3

OLIGURIC PHASEInc ASO, antistreptokinase


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Clinical Manifestations

Hematuria Proteinuria

Edema

Hypertension

Oliguria

Nonspecific symptoms

Abdominal pain

Malaise

Fever


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Stages

- typical course lasts 7-10 days for each ofthe 3 phases

Oliguric phase acute salt and wateroverload

Diuretic phase BP normalizes

Convalescent phase


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Diagnosis

Urinalysis

CBC

Blood chemistries

C3, ASO

Renal biopsy


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Complications

Acute Renal Failure

Hypertensive encephalopathy

Congestive Heart failure


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Treatment

Supportive

Diet low Na, low protein

Activity

Medications

Antibiotic Penicillin, Erythromycin

Anti-hypertensive drugs Furosemide,vasodilators, ACEI


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Prognosis

More than 95% of affected children eventuallyrecover totally with conservative therapy aimedat maintaining sodium and water balance.

Robbins, Pathologic Dses, 6th ed


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Follow-up Care

Proper education about patients condition

Ff-up every 2 weeks with urinalysis result

8-10 weeks after onset C3 determination

12 mos after onset serum Crea in normal level


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SUMMARY


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Thank You!

Psgn _acute Glomerulonephritis

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