2. CASE OBJECTIVES GENERAL To present a case of acute glomerulonephritis SPECIFIC Discuss history and physical examination results Discuss salient features and differentials Discuss plan of management
4. General data A.N.D. 5 years old, male, born on 13 August 2005, Filipino, Roman Catholic, from Rosario, Pasig Admitted for the first time at present institution: (5 August 2010) Informant: Mother w/ 80% reliability
12. Review of systems General No fever, no weight gain/loss, weakness, fatigue Skin No rashes, no sores, no changes in hair/nails, no gout MSK No muscle/ joint pains, no joint swelling HEENT No headache, blurring of vision, tinnitus, deafness Respiratory No dyspnea, hemoptysis Cardiovascular No palpitations, chest pains Gastrointestinal No nausea, vomiting, dysphagia, heartburn, rectal bleed Genitourinary No dysuria, NO FREQUENCY, NO Endocrine No excess sweat, heat intolerance, polyuria, excessive thirst, cold intolerance
13. Past medical History Bacterial Meningitis (2005) superimposed with Nosocomial Pneumonia, RITM (1 month) Surgeries None Allergies None to food or medications
14. Past medical History Immunization (Local Health Center) BCG HepB 1-2-3 DPT 1-2-3 OPV 1-2-3 Measles
15. Maternal and Birth history Full-term via Normal Spontaneous Delivery to a 22 year old G3P3 (3003) at Home assisted by a Midwife Spontaneous cry, Good activity Birth weight and APGAR unrecalled No significant maternal illness/ comorbidities IrregPNCu
16. Feeding History Breastfed until 1 year, then weaned Formula milk (Sustagen) at 2 years old Current diet: Chicken, rice, some vegetables, pancit canton, cooked by mother
17. Developmental History Smiled at 2 months Mama, dada at 8 months Walks alone at 1 year Jumps at 2 years Stories at 3 years Writes name, alphabet, dresses w/o supervision at 4 years Draws complete person without clothing, basic math at 5 years
19. Personal and Social History Home Informal settlers House near the road Family shares 1 room Water source NAWASA Parents are unemployed Education Patient at local daycare Older siblings at local elementary school
21. Physical Examination General Awake, ambulatory, anxious, not in cardiorespiratory distress Vital Signs BP 110/80 (>99th %) HR 97 RR 20 T 37.1°C Anthropometrics Height 103cm Weight 17.4kg BMI 16.4kg/m2 Height for age 25th p Height for weight 50th p Weight for age 25th p
22. Physical Examination Skin No lesions, rashes, or color changes Good skin turgor (CRT <1 second) Head and Scalp No lesions, infections, infestations Abundant, fine black hair Eyes Conjugate gaze, anicteric sclera, pink palpebral conjunctiva No edema, deformities, lesions, ptosis, erythema, or discharge Pupils 2mm BRTL, no RAPD EOMs full and equal Presence of Red Orange Reflex, Anterior Chamber deep
23. Physical Examination Ears External ears retractable, no pain, gross deformities or discharge Canals intact, abundant cerumen, foreign body noted on right canal Cone of light present, tympanic membrane intact both ears Nose Septum midline, nares patent Turbinates pink, no discharge Mouth Lips and buccal mucosa pink and moist Cavities on teeth Tongue midline Tonsillopharyngeal congestion
24. Physical Examination Neck Supple, Cervical Lymphadenopathies present No pulsations, neck engorgement, lesions or masses Lungs No lesions, rashes, or changes in color Symmetric chest expansion, equal tactile fremiti in all lung fields Bronchovesicular breath sounds, no rales/crackles, no rhonchi Chest Adynamic pericardium Apex beat at 4th ICS MCL Normal rate, regular rhythm No murmurs
25. Physical Examination Abdomen Flat, smooth, no lesions, rashes Hypoactive bowel sounds Tympanic in all quadrants No masses, tenderness, organomegaly (-) Goldflam test Genitourinary Grossly male Testes descended No phimosis Extremities No cyanosis or clubbing, no fractures or deformities Full and equal pulses, no edema
26. Physical Examination Neuroexamination General Behavior was appropriate, cooperative to examiner, euthymic, appropriate affect, normal and spontaneous speech Sensorium Awake, Oriented to person, place and time, Memory intact, Calculation intact Fund of information, Insight, Judgment and Planning appropriate for age No agnosia or apraxia GCS 15/15
27. Physical Examination Neuroexamination Cranial Nerves I – not tested II – visual acuity intact, gaze conjugate III, IV, VI – no ptosis, EOMs full and equal V – masseter and temporalis muscle bulk and strength symmetric and normal, present corneal reflex VII – facial muscles bulk and strength symmetric and normal VIII – (+) finger rub test both ears IX, X – palatal elevation and swallow are symmetric, normal XI – SCM and trapezius contour, bulk and strength normal XII – tongue is midline, no atrophy or fasciculations
28. Physical Examination Neuroexamination Motor Normal gait and rhythm No hypertrophy/atrophy, involuntary movements Muscle tone symmetric and equal Strength 5/5 in all Superficial sensory Briskly withdraws to pain DTR 3+ in all Cerebellar Intact Meningeals Neck supple, (-) Kernigs, (-) Brudzinski, (-) Ankle clonus
29. Laboratories Urinalysis (Non-institutional) Amber-colored, turbid urine WBC TNTC*/hpf RBC TNTC*/hpf Albumin ++++ many Sugar (-) Bacteria many Hyaline casts +++ many * Too numerous to count
32. Salient Features 5 year old Male History of URTI 1 week PTA BP elevated for age Edema Gross hematuria No headache/ blurring of vision No abdominal pain No skin lesions
43. A. DEFINITION Glomerulonephritis Glomerular injury with evidence of proliferation and inflammation of glomerulus such as leukocyte infiltration, antibody deposition, and complement activation
44. A. DEFINITION Characterized by hypertension, edema, gross hematuria, proteinuria, azotemia Incidence All age groups Greatest frequency in 4-12 years Peak 5-6 years Male:Female 2:1 Seasonal Pattern Winter-Spring: Streptococcal pharyngitis related AGN Summer-Fall: Pyoderma related post strep AGN
45. B. CLASSIFICATION Etiology Post-infectious Bacterial Streptococcus Pneumococcus Staphylococcus Gonococcus Syphilis Viral Measles, mumps, varicella, Inf mononucleosis, CMV, HepB, Coxsackie Non-infectious Clinical Manifestation Primary Renal failure Secondary Systemic diseases (SLE, HSP) Most Common Causative Agent Group A Beta hemolytic streptococcusType 12
46. C. immunopathogenesis Antigen-IgG-C3 complex Antigen-Antibody Immune Response Infiltration of Inflammatory cells Proliferation of glomerular cells Matrix expansion Basement membrane permeability Antibody titers Antistreptolysin O Antihyaluronidase DNAse-B Streptokinase Glomerular filtration surface Glomerular Filtration Rate Na+ and water retention Oliguria, Hypertension, Edema, Hematuria
47. D. Clinical course Latent Phase (~10 days) Onset of infection to development of clinical disease Strep pharyngitis Strep pyoderma
48. D. Clinical course Oliguric Phase (~7-10 days) Edema (85%) Appears abruptly, most common symptom Periorbital, later generalized Dependent on Severity of glomerular involvement Fluid intake Degree of hypoalbuminemia Resolves in 5-10 days
49. D. Clinical course Oliguric Phase (~7-10 days) Hematuria (30-50%) Dark brown, rusty, cola Disappears within 1-3 wks Microscopic: 1-2wks after initial presentation
50. D. Clinical course Oliguric Phase (~7-10 days) Hypertension (50-90%) Pathogenesis unknown ECF volume expansion Occurs early, lasts 3-5 days Severe after a brief 2-5 days Magnitude of increase is variable Systolic 200mmHg Diastolic 120mmHg Persistent BP elevation for 1-2 wks Returns to normal within 2-3 wks, persists up to 6 wks
51. D. Clinical course Oliguric Phase (~7-10 days) Other signs and symptoms Anuria Azotemia
53. E. Diagnostic work-up Urinalysis High specific gravity High osmolality Low pH Proteinuria rarely exceeds +3 Disappears in first 2-3months or may decrease slowly over 6 months RBC casts 60-85% hospitalized w/ AGN Leukocyturia, hyaline, and granular casts common CBC Anemia (dilutional) may be present
54. E. Diagnostic work-up Serum Chemistries Serum function test BUN, Crea BUN elevated, disproportionate to serum creatine Serum electrolytes Hyponatremia, Hypokalemia
55. E. Diagnostic work-up Immunologic ASO titer Rises over 10-14 days to several wks in 70-80% after strep infection, peak in 3-5 months Slowly decreases in 1-6 months Poor titer following pyoderma AGN titer C3 Depressed in 90-100% patients in first 2wks of illness (Although not always low) Normal in 3-8 weeks Persistent levels suggest ongoing, chronic process
56. E. Diagnostic work-up Radiologic KUB Ultrasound Prominent pyramids Echogenic cortex No detectable architecture Chest Xray “sunburst” pattern
57. F. Confirmatory investigation Bacteriologic demonstration of group A ß hemolytic strep on throat and skin Serology High ASO titers Bacteriologic Anti-DNAseHyaluronidase Pyoderma Streptozyme test 100% Confirmatory of Strep Depressed C3
58. F. Confirmatory investigation Kidney Biopsy Atypical presentation Absence of infection prior to onset Absence of serologic evidence of streptococcal etiology Absence of depression of serum complement or C3 Early clinical course Anuria Presence of nephrotic syndrome Azotemia out of proportion to other clinical findings
60. F. Confirmatory investigation Delay in Resolution Early Oliguria + Azotemia >2 wks HPN >3 yrs Gross hematuria >3 wks C3 persistently depressed >6wks Late Proteinuria + hematuria > 6 mos. Proteinuria > 6 months Hematuria > 12 mos.
61. G. Treatment Supportive Low salt diet, Fluid restriction BSA + ½ of the UO if on Furosemide or 20-30ml/kg/BW Indications for Hospitalization Edematous Hypertension Oliguric w/ Azotemia S/Sx of Congestion
62. G. Treatment Medications Uncomplicated (80%) Diuretics Furosemide (0.5-1mkd, max 8-15mg) Antihypertensive beta-blockers Hydralazine (0.15-0.30mg/kg) Propanolol (1mkday every 6-12 hours)
63. G. Treatment Medications Complicated HPN Encephalopathy HTN severe + Nervous System dysfunction Headache, vomiting, depressed sensorium, confusion, visual disturbances, Aphasia, memory loss, coma, convulsion Anti-convulsants (Diazepam, Phenobarbital) Anti-hypertensive CHF Dyspnea, orthopnea, cough, rales often IV furosemide Careful digitalization Phlebotomy
64. G. Treatment Medications Complicated Acute Renal Failure IV Furosemide Peritoneal dialysis Other medications Pen G 100,000 ‘U’ for PSAGN 7-10 days
65. H. Indications for referral Atypical presentation – massive proteinuria Systemic signs Complications
66. I. Prognosis Prognosis for complete recovery from AGN in children is excellent (80-90%). Recovery without any measurable renal abnormality is expected Clinical recovery at 1 month Gross hematuria – 1-2 wks Microscopic hematuria – 6months to 1 year Serologic tests C3 – 8-12 wks Biopsy Histologic resolution – 1-2 years
67. I. Prevention Early treatment does not eliminate risk of GN Family members should be cultured for Grp A ß hemolytic strep and treated if culture positive