Acute post streptococcal glomerularonephrites in children investigation and management

1. Case discussion

2. Patient Biodata:
Name: Hashim
Age : 8years
Gender: Male
Resident of Kargha
Date of add: 20/09/2023

3. Presenting complains:
Pustular eruption on whole body for 14 days
Cough 4days
Fever 4 days
Swelling of hands and feet for 3 day
Breathing difficulty for 2 days

4. HOPI:
According to parents, patient was doing well 2
weeks ago when he developed pastular eruption
on whole body. Initially started to apear on both
hands and then gradually devloped on whole body
within a week with pussy discharge and associated
with itching.
Patient has history of cough which was non
productive, moderate to severe in intensity
continuous, aggrevated on lying flate and no
relieving factor noted by attendants/pateint ;
associated with breathing difficulty; which was
gradually started at rest and progressively
increased in intensity over time and aggrevated by
lying flate and exertion and relieved by sitting
erect.

5. Patient has also history of high grade fever which was
intermttent associated with rigors and not relived by
taking syp panadol.
He has also history of swelling of hands/feets and
periorbital region from last 3 days.
Patient has also history of passing red colored urine
from last 3-4 days.
There is no history of fits, LOC, photophobia
photosensitivity, oral ulcers, loose motion, vomiting,
constipation, abdominal distension, abdominal pain,
hematemesis, malena, joint pain joint swelling and no
history of any trauma.

6. Past history: past medical and surgical history is not
significant.
Vaccination history:
Not vaccinated child.
Family history:
Both parents are alive and healthy.
6 sibs one sister and five brother all are alive and healthy
there is no history of any chronic disease in family.
Birth history:
Birth history is uneventful, SVD at home.
Developmental milestones achieved in time.
Socioeconomical history: Belongs to low socio -
economical status. Own home containing one room and
one washroom.

7. On examination:
A Sick looking, puffy child with obvious respiratory
distress and pallor heaving vitals,
Pulse rate: 130/mint
R/Rate: 60/mint
TEMP: 100F
BP: 140/120.
PO2: 52% at room air.
weight 28kg
Bilateral pedal edema is present
Bilateral normal vesicular breathing, slightly decreased air
entery,B/L chest crepitation more on right lower chest.

8. Abdomen is distended and tender right
hypochondrium.
Liver is palpable 5cm BRHC.
S1 and s2 audible no abnormal sound
appreciated.
CNS Grossly Intact,
GCS 15/15
Reflexes were intact.

9. Investigations:
CBC
Tlc 16.9 neu 86%
Hb 12.2 g/dl lym21.3%
Mcv 79fl
Plt 593/ul
Renal function test
Serum urea 39mg/dl
Serum creatinine 1mg/dl

10. Serum electrolyte
Sodium: 143mmol/dl
Potassium: 4.7mmol/dl
Chloride: 112mmol/dl
Bicarbonate: 20.7mmol/dl
PH: 7.6
Urine RE:
Albumin: trace.
Wbcs: 2-3/hpf
RBCS: numerous.

11. RBS: 93mg/dl.
Serum cholesterol: 122mg/dl.
Serum triglyceride: 114mg/dl.
Uric acid: 5mg/dl
Serum albumin: 2.3g/dl.
ASO TITRE: 534.7iu/ml

12. Urine albumin to creatinine ratio.
Urine microalbumin: 1696.2mcg/l
Urine creatinines: 73.6mg/dl
UACR =23.04.
Xray reporting:
Non homogenous opacification of right
midlower lung zone representing acute
consolidative changes.
b/l hilar congestion.
b/L cp angle are intact.

13. ECHO REPORT:
LVEF: 45-50%
SWMA shows mild global hypokinesia (post
myocarditis sequel)

14. Differential diagnosis:
Acute glomerulonephritis (post streptococcal)
IgA nephritis.
Lupus nephritis.
Acute kidney injury.
Good pasture syndrome:
nephrotic syndrome:

15. Management:
Initial general management include:
NPO.
Maintain iv line.
O2 inhalation e urgent cpep
Prop up position.
Pass NG tube.
Foleys catheter.
Input output monitoring.
BP monitoring.
Vitals monitoring.
Send labs.

16. Treatment:
Started e
Inj calamox 600mg tds
Inj ceftrixone 1g iv bd
Inj lasix 20 mg bd
Later on treatment modified on the basis of lab
reports include
Stop inj calamox and ceftrixone:
Inj meropenum 500mg tds
Inj vancomycin 500mg tds
inj lasix 25mg 8 hourly
inj dexa 2.5mg iv tds
Tab dispirin 300mg ½ od

17. Tab zestril 2.5mg od
Tab ronsta 5mg HS.
Tab digoxin 0.25mg half tab od (after echo
report).
NOW (today)
Patient was started
NG feed 60ml 3 hourly
Inf peads solution 25ml/hr
Tab spiromide 30mg 12 hourly

18. Acute Glomerulonephritis:
An acute inflammation of renal glomerular
parenchyma due to deposition of immune
complexes characterized by sudden onset of
oliguria hematuria, hypertension, and edema.
:Etiology:
Streptococcal infection.(beta hemolytic group
A)
Non streptococcal.
Bacterial: infective endocarditis, shunt
nephritis, syphilis, S pneumonia.

19. Viral causes: HBV, mumps, varicella, coxackie
infective mononucleosis.
Autoimmune: good pasture syndrome ,
HSP,SLE, IgA nephropathy.
Pathology:
Gross:
Both kidneys enlarged.
Ischemic
Microscopy:
Glomeruli enlarged,infiltrated by polymarphs
and epithelial crescents.

20. Immunofluorescence:
Lumpy bumpy deposition of igG antigen and
c3.
Electron microscopy:
Mesangial proliferation and mesangial matric
deposition.
Lump of immune deposition on the epithelial
side of GBM.

21. Pathophysiology:
Oliguria:
Spasm of afferent arteriole (decrease blood flow).
Obliteration of lumen by mucosal edema and cellular
infiltration.
Crescents causes obstruction.
Increased absorption of Na and water from renal tubules.
Hypertension:
Increase absorption of Na and water from renal tubules.
Inc sympathetic activity.
Inc arterial spasm.
Inc cardiac output.
Oedema:
Retention of Na and water from renal tubules.
Circulation of unknown antigen causing peripheral
vasodilatation.

22. Post streptococcal glomerulonephritis:
Etiology:
Usually occurs 7-14 days after throat infection
and 2-6 weeks after skin infection by group A B-
hemolytic streptococci.
Streptococcal antigens involved in immune
reaction i.e zymogen precursor of exotoxin.
Age group:
5-12 years
Male predominance.
Seasonal variation: during winter and rainy
season serotype M1 M4 and M12 causes acute
pharyngitis and during summer serotype M49
causes skin infection.

23. Pathogenesis:
Cross reaction of streptococcal pyogenic exotoxin-b and other M
proteins with the various component of glomerular basement
membrane.
Type 3 immunological reaction in which glomeruli are damaged due
to deposition of igG antibody antigen and complement c3.
Clinical features:
Fever.
Facial puffiness.
Edema feet
Oliguria
Cola colored urine, breathing difficulty, hypertension, abdominal
pain.
Atypical presentation include hypertensive encephalopathy i.e
confusion convulsion etc.
Pulmonary edema due to CHF
Acute renal failure

24. DIAGNOSTIC CRITERIA:
At least two of the following criteria must be
present.
1:positive throat or skin culture for
streptococcus.>confirmatory or carrier state.
2:Streptococcal product like anti streptokinase
anti DNAse B ASO titre are elevated.
3:Hypocomplementemia> serum c3 reduced
by 90% but c4 is normal.

25. Ivestigations:
Urine analysis:
Proteinuria> non selective 1+ or 2+ e red
cells.
hematuria:
RFTS:
Blood urea and creatinine increses due to dec
GFR.
Low c3 complement.
ASO TITRE.
ESR (Increased)
c3 and c4 levels.
throat swab culture and anti DNAse B
antibody.

26. Management:
Give complete bed rest.
Vital monitoring.
Fluid and salt restriction.
Input output monitoring.
Daily weight monitoring.
Propped up position and provide oxygen.
Mange hypertension: (anti hypertensive drugs e.g ca
channel blocker ACE inhibitors )
Diuretics if significant edema fluid overload are
present.
Infection control by antibiotics e.g penicillin to
eradicate streptococci in throat or skin.
Management of complications, like CCF hypertensive
encephlopathy,.

27. Complications:
Hypertensive encephalopathy.
Hypertensive heart failure.
Hypocalcaemia.
Hyperkalemia.
Acute renal failure.
hyperphosphatemia
Prognosis:
Complete recovery in 95% cases.
1-5% mortality.
1-5% develops chronic GN, chronic renal failure.

28. •
• Thank you: