CASE

History of Present Disease

A 5 month old boy (MSP/ MR 55 86 73) was admitted at May 9th, 2013 to hospitalization
Haji Adam Malik with chief complained history shortness of breath since three months and
getting worse for the last one and half months. The shortness of breath is not related to the
weather, but it getting worse by the activity. Dyspnea usually occur after he cried or
sneezing and blue appearance showed but it disappear immediately. History of
discontinuity while suckle found. History sweating while suckle was not found. History of
fever, loss of appetite, and weight loss was not found. Those patient come to RSUP HAM
as a referral from the Sufina Azis Hospital and already diagnosed as a Moderate PDA with
good LV function examined by echocardiography and planned to get Transcatheter PDA
Closure.

He was born in hospital through caesarean section assisted by obstetrician and

gynaecologist, birth body weight was 3000 gram and the birth body length was 46 cm but
the APGAR score was not recorded. Mothers age 39 years old and history of previous
hypertension was found.

History of Development

- Following object direction : 1 month

- Smile : 2 months
- Laughing : 3 months
- Head lifting : 4 months
- Turning away : 4 months

History of Feeding

- Breast feeding : was given from birth until now

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History of Immunization
- BCG : 2 month
- DPT : 2, 4 months
- Polio : 0, 2, 4 months
- HBV : 0, 1, 6 months

History of previous illness : unclear

History of previous medications : unclear

Physical Examination
Generalized status
Body weight: 6,3 kg, Body length: 59 cm,
Upper arm circumference: 12 cm, Head circumference: 40 cm
BW/BL : 2<Z<1
BW/age : -2 < Z < 0
BL/age : -3 < Z < -2

Presens status
Consciousness: Alert Heart Rate: 104 x/i
Body temperature: 36,2C Respiratory Rate: 32x/i
General condition was moderate and nutrition condition was good.

Anemic (-). Icteric (-). Cyanosis (-). Edema (-). Dyspnea (-).

Localized status
Head :
Inferior palpebra conjunctiva pale (-/-). Icteric sclera (-). Light reflex (+/+). Isochoric pupil.
Corneal ulcer (-). Bitots spot (-). Ear, nose. mouth were within normal limit.

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Neck :
Lymph node enlargement (-). JVP R-2 cmH2O.

Thorax:
Symmetrical fusiformis. Chest retraction (-). HR: 104 bpm, reguler, grade III/VI ICR II/III
LMCS continous murmur (+). RR: 32x/i, reguler. Breath sound: vesicular. Rales (-/-).

Abdomen:
Soepel, peristaltic (+) N, Hepar/Lien: not palpable

Extremities:

Upper extremities Pols: 104 x/i, regular, adequate pressure/volume, CRT < 3, warm,
Lower extremities: oedem (-/-)

Urogenital:
Male, within normal limit

Chest X-Ray on RS Sufina Azis (May 6th 2013)

Echocardiography Result (May 7th 2013) :

Moderate PDA with Good LV Function

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Differential Diagnosis:
Moderate PDA + Left sided Hypertrophi with Good LV Function
Working Diagnosis:
Moderate PDA + Left sided Hypertrophi with Good LV Function
Management:
Furosemid 2 x 6 mg
Aldacton 2 x 6,25 mg

Diagnostic Planning:
Transcatheter PDA closure

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Follow up on May 9th-10th 2013
May 9th 2013
S Shortness of breath (+)
O Sensorium: compos mentis
Temperature: 37.2C
BW: 6.3 kg
BL: 59 cm
Head : Eyes : Light reflexes : +/+,
isocoric, conjunctiva
palpebra was not pale
Ear, and mouth : normal
Nose : nasal canule
Neck : lymph node was not
palpable
Chest : Simmetrical fusiformis, no
retraction
HR : 100 bpm, reguler,
grade III/VI ICR II/III
LMCS continous murmur
(+)
RR : 30 breathes/minute,
reguler, no rales
Abdomen : Soepel, peristaltic (+)
normal, liver and spleen
unpalpable
Extremities : pulse 100 bpm, reguler,
pressure and volume were
adequate, warm acral,
CRT <3
A Working Diagnosis :
Moderate PDA with good LV function
P O2 L/I nasal canule
Furosemide 2 x 6 mg
Aldactone 2 x 6.25 mg
Nebule / 6 hr with NaCl 0.9% 2.5 cc
May 10th 2013
Shortness of breath (+)
Sensorium: compos mentis
Temperature: 36.7C
BW: 6.3 kg
BL: 59 cm
Head : Eyes : Light reflexes : +/+,
isocoric, conjunctiva palpebra
was not pale
Ear and mouth : normal
Nose : nasal canule fixed
Neck : lymph node was not palpable
Chest : Simmetrical fusiformis, no
retraction
HR : 98 bpm, reguler, grade
III/VI ICR II/III LMCS
continous murmur (+)
RR : 26 breathes/minute,
reguler, no rales
Abdomen : Soepel, peristaltic (+) normal,
liver and spleen unpalpable
Extremities : pulse 98 bpm, reguler,
pressure and volume were
adequate, warm acral, CRT
<3.
Working Diagnosis :
Moderate PDA with good LV function
O2 L/I nasal canule
Furosemide 2 x 6 mg
Aldactone 2 x 6.25 mg
Nebule / 6 hr with NaCl 0.9% 2.5 cc
Diet MII 630 kkal + 12 gr protein
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Laboratory result : May 10th 2013

Parameters Value Normal Value

Complete Blood Count
Hemoglobin 10,60 gr% (10,7 17,1) gr%
Erithrocyte 4.84 x 106 /mm3 (3.75-4.95) x 106 /mm3
Leucocyte 13.35 x 103 /mm3 (6.0-17.5) x 103 /mm3
Hematocrite 33.10 % (38-52) %
Trombocyte 649 x 103 /mm3 (217-497) x 103 /mm3
MCV 68.40 fL (93-115) fL
MCH 21.90 pg (29-35) pg
MCHC 32.00 g% (28-34) %
RDW 14.90 % (14.9-18.7) %
MPV 7.90 fL (7.2-10.0) fL
PCT 0.51%
PDW 8.3 fL
Diftel
Neutrofil 20.70 % (37-80) %
Limfosit 64.90 % (20-40) %
Monosit 10.90 % (2-8) %
Eosinofil 3.10 % (1-6) %
Basofil 0.400 % (0-1) %
Neutrofil absolute 2.76 x 103/L (1.9-5.4) x 103/L
Limfosit absolute 8.66 x 103/L (3.7-10.7) x 103/L
Monosit absolute 1.46 x 103/L (0.3-0.8) x 103/L
Eosinofil absolute 0.42 x 103/L (0.20-0.50) x 103/L
Basofil absolute 0.05 x 103/L (0-0.1) x 103/L

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Faal Hemostatic
Bleeding Time 3.30 minute < 5 minute
PT + INR
Protrombine Time
Control 13.20 sec
Patient 15.6 sec
INR 1.20
APTT
Control 29.9 sec
Patient 39.6 sec
Trombine time
Control 13.2 sec
Patient 13.4 sec
Clinic Chemistry
Hepar
Total bilirubin 0.39 mg/dL <1
Direct bilirubin 0.33 mg/dL 0 0.2
Fosfatase alkali (ALP) 338 U/L < 449 U/L
AST/SGOT 45 U/L < 38 U/L
ALT/SGPT 17 U/L < 41
Carbohydrate Metabolism
Blood glucose (at the time) 106.00 mg/dL < 200 mg/dL
Renal
Ureum 26.40 mg/dL < 50 mg/dL
Creatinine 0.37 mg/dL 0.17-0.42 mg/dL
Uric acid 5.1 mg/dL < 7.0 mg/dL
Electrolyte

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Natrium (Na) 132 mEq/L (135-155) mEq/L
Kalium (K) 4.9 mEq/L (3.6-5.5) mEq/L
Phospor 6.3 mEq/L (5.0-10.8) mEq/L
Chlor (Cl) 96 mEq/L (96-106) mEq/L
Magnesium (Mg) 2.58 mEq/L (1.4-1.9) mEq/L
Immunoserology
Hepatitis
HBsAg Negative Negative
Hepatitis A Profile
Anti HAV Total 60.00 Negative
(Negative < 20
Positive >= 20)
Hepatitis C
Anti HCV Negative Negative

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 May 11st 2013 May 12th 2013
S Shortness of breath (+) Shortness of breath (-)
O Sensorium: compos mentis Sensorium: compos mentis
Temperature: 37C Temperature: 37C
BW: 6.3 kg BW: 6.2 kg
BL: 59 cm BL: 59 cm

Head : Eyes : Light reflexes : +/+, Head : Eyes : Light reflexes : +/+,
isocoric, conjunctiva isocoric, conjunctiva palpebra
palpebra was not pale was not pale
Ear and mouth : normal Ear and mouth : normal
Nose : nasal canule fixed Nose : nasal canule fixed
Neck : lymph node was not Neck : lymph node was not palpable
palpable Chest : Simmetrical fusiformis,
Chest : Simmetrical fusiformis, retraction (+) epigastrial
retraction (+) in HR : 90 bpm, reguler, grade
epigastrial III/VI ICR II/III LMCS
HR : 100 bpm, reguler, continous murmur (+)
grade III/VI ICR II/III RR : 40 breathes/minute,
LMCS continous murmur reguler, no rales
(+) Abdomen : Soepel, peristaltic (+) normal,
RR : 25 breathes/minute, liver and spleen unpalpable
reguler, no rales Extremities : pulse 90 bpm, reguler,
Abdomen : Soepel, peristaltic (+) pressure and volume were
normal, liver and spleen adequate, warm acral, CRT
unpalpable <3.
Extremities : pulse 100 bpm, reguler,
pressure and volume were
adequate, warm acral,
CRT <3

A Working Diagnosis : Working Diagnosis :

Moderate PDA with good LV function Moderate PDA with good LV function

P O2 L/I nasal canule O2 L/I nasal canule

Furosemide 2 x 6 mg Furosemide 2 x 6 mg
Aldactone 2 x 6.25 mg Aldactone 2 x 6.25 mg
Nebule / 8 hr with NaCl 0.9% 2.5 cc Nebule / 8 hr with NaCl 0.9% 2.5 cc
Diet MII 630 kkal + 12 gr protein Diet MII 630 kkal + 12 gr protein
R/ ADO R/ ADO

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 May 13th 2013 May 14th 2013
S Shortness of breath (-) Shortness of breath (+)
O Sensorium: compos mentis Sensorium: compos mentis
Temperature: 37C Temperature: 36.8C
BW: 6.2 kg BW: 6.2 kg
BL: 59 cm BL: 59 cm

Head : Eyes : Light reflexes : +/+, Head : Eyes : Light reflexes : +/+,
isocoric, conjunctiva isocoric, conjunctiva palpebra
palpebra was not pale was not pale
Ear and mouth : normal Ear and mouth : normal
Nose : nasal canule fixed Nose : nasal canule fixed
Neck : lymph node was not Neck : lymph node was not palpable
palpable Chest : Simmetrical fusiformis,
Chest : Simmetrical fusiformis, retraction (+) epigastrial
retraction (+) in HR : 108 bpm, reguler, grade
epigastrial III/VI ICR II/III LMCS
HR : 100 bpm, reguler, continous murmur (+)
grade III/VI ICR II/III RR : 30 breathes/minute,
LMCS continous murmur reguler, no rales
(+) Abdomen : Soepel, peristaltic (+) normal,
RR : 38 breathes/minute, liver and spleen unpalpable
reguler, no rales Extremities : pulse 108 bpm, reguler,
Abdomen : Soepel, peristaltic (+) pressure and volume were
normal, liver and spleen adequate, warm acral, CRT
unpalpable <3.
Extremities : pulse 100 bpm, reguler,
pressure and volume were
adequate, warm acral,
CRT <3

A Working Diagnosis : Working Diagnosis :

Moderate PDA with good LV function Moderate PDA with good LV function

P O2 L/I nasal canule O2 L/I nasal canule

Furosemide 2 x 6 mg Furosemide 2 x 6 mg
Aldactone 2 x 6.25 mg Spinorolactone 2 x 6.25 mg
Nebule / 8 hr with NaCl 0.9% 2.5 cc Nebule / 8 hr with NaCl 0.9% 2.5 cc
Diet MII 630 kkal + 12 gr protein Diet MII 630 kkal + 12 gr protein
R/ ADO R/ ADO

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 May 15th 2013 May 15th 2013 (follow up post trancatheter
closure)
S Shortness of breath (-) Bleeding (-)
O Sensorium: compos mentis Sensorium: compos mentis
Temperature: 37.1C Temperature: 36.9C
BW: 6.2 kg BW: 6.2 kg
BL: 59 cm BL: 59 cm

Head : Eyes : Light reflexes : +/+, Head : Eyes : Light reflexes : +/+,
isocoric, conjunctiva isocoric, conjunctiva palpebra
palpebra was not pale was not pale
Ear and mouth : normal Ear and mouth : normal
Nose : nasal canule fixed Nose : nasal canule fixed
Neck : lymph node was not Neck : lymph node was not palpable
palpable Chest : Simmetrical fusiformis,
Chest : Simmetrical fusiformis, retraction (+) epigastrial
retraction (+) in HR : 128 bpm, reguler,
epigastrial murmur (-)
HR : 110 bpm, reguler, RR : 30 breathes/minute,
grade III/VI ICR II/III reguler, no rales
LMCS continous murmur Abdomen : Soepel, peristaltic (+) normal,
(+) liver and spleen unpalpable
RR : 36 breathes/minute, Extremities : pulse 128 bpm, reguler,
reguler, no rales pressure and volume were
Abdomen : Soepel, peristaltic (+) adequate, warm acral, CRT
normal, liver and spleen <3.
unpalpable
Extremities : pulse 110 bpm, reguler,
pressure and volume were
adequate, warm acral,
CRT <3

A Working Diagnosis : Working Diagnosis :

Moderate PDA with good LV function Post transcatheter PDA closure (H-1)

P O2 L/I nasal canule Inj Ceftriaxone 300 mg/12 hr/IV (2x)

Furosemide 2 x 6 mg Diet MB 620 kkal + 12 gr protein
Spironolactone 2 x 6.25 mg
Nebule / 8 hr with NaCl 0.9% 2.5 cc
Diet MII 630 kkal + 12 gr protein
R/ ADO (15/5/2013)

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Cath and Transcatheter PDA Closure (May 15th 2013)

Conclusion : Succesful Transcatheter PDA Closure with Heart 4/6

No residual PDA and no Coarctation

Advice : Keep NBM till fully aware

Guidance IV ceftriaxone 250 mg 2x

Watch bleeding at puncture site and pulsation

Plan for tomorrow : Chest X-Ray (AP and lateral) and Echocardiography

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 May 16th 2013 May 17th 2013
S Shortness of breath (-), fever (-), Cough (+) Cold (-), Fever (-)
weakness (+)
O Sensorium: compos mentis Sensorium: compos mentis
Temperature: 36.7C Temperature: 36.8C
BW: 6.2 kg BW: 6.2 kg
BL: 59 cm BL: 59 cm

Head : Eyes : Light reflexes : +/+, Head : Eyes : Light reflexes : +/+,
isocoric, conjunctiva isocoric, conjunctiva palpebra
palpebra was pale (+/+) was pale (+/+)
Ear, nose, and mouth : Ear, nose, and mouth : normal
normal
Neck : lymph node was not Neck : lymph node was not palpable
palpable Chest : Simmetrical fusiformis,
Chest : Simmetrical fusiformis, retraction (+) epigastrial
retraction (+) in HR : 96 bpm, reguler, grade
epigastrial murmur (-)
HR : 100 bpm, reguler, RR : 30 breathes/minute,
murmur (-) reguler, no rales
RR : 36 breathes/minute, Abdomen : Soepel, peristaltic (+) normal,
reguler, no rales liver and spleen unpalpable
Abdomen : Soepel, peristaltic (+) Extremities : pulse 96 bpm, reguler,
normal, liver and spleen pressure and volume were
unpalpable adequate, warm acral, CRT
Extremities : pulse 100 bpm, reguler, <3.
pressure and volume were
adequate, warm acral,
CRT <3

A Working Diagnosis : Working Diagnosis :

Post Transcatheter PDA Closure Post Transcatheter PDA Closure

P Inj. Ceftriaxone 300 mg/12 hr/IV (H1) Inj. Ceftriaxone 300 mg/12 hr/IV (H1)
Diet MB 620 kkal + 12 gr protein Diet MB 620 kkal

R/ Echocardiography R/ Foto Thorax PA

Chest X-Ray PA Patient may came home and have to
control on schedule
Echocardiography 1 week later

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Echocardiography (May 16th 2013) Device in situ, no residual PDA

No LPA stenosis

No coarctation

Chest X-Ray (May 17th 2013)

Chest X-Ray (May 17th 2013) Bronchopneumonia dextra

Dilatation aorta

DISCUSSION

Acute glomerulonephritis, essentially a disease of child hood that accounts for 90% of renal
disorders in children. Acute glomerulonephritis (AGN) is a disease characterized by the
sudden appearance of edema, hematuria, proteinuria, and hypertension.7

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In this case, the chief complained are oedema in eyelids, face, and both of legs for six days.
The blood pressure is found hypertension, 150/90 mmHg. From urine dipstick, protein is
+3 and blood is +2 which mean he had proteinuria and hematuria.

The group A beta-haemolytic streptococcus (GAS) is a common infective agent in children

that causes the widest range of clinical disease in humans of any bacterium. Infection can
be that of respiratory tract in the form of pharyngitis, otitis media or skin infections like
pyoderma, impetigo or infected scabies.7 Not all types of streptococcus cause kidney
problems but only those caused by nephritogenic strains.8 APSGN has latent period for 1-
2 weeks in upper respiratory tract infection and 3 weeks in pyoderma.1

In this case, the patient had history of fever not too high three weeks ago. Redness spotting
was found on the skin. History of dysphagia was experienced for this two years. It shows
the possibility of streptococcal infection.

Acute poststreptococcal glomerulonephritis typically affects children between the ages of 2

and 14 years, but 10% of cases are patients older than 40. It is more common in males, and
the familial or cohabitant incidence is as high as 40%.3 The patient in this case is 14 years
old.

Important laboratory findings include an elevated streptococcal exoenzyme

(antistreptolysin O) titer, a decline in C3 complement, and cryoglobulins (i.e., large
immune complexes) in the serum.2 In this case, the patient had high level of ASO (400) and
hypocomplementemia (33mg/dL)

APSGN case can be classified in three part, confirm, probable, and possible case.

1. Confirmed case
A confirmed case requires either:
a. laboratory definitive evidence
OR
b. laboratory suggestive evidence AND clinical evidence.
2. Probable case
A probable case requires clinical evidence only.
3. Possible case
A possible case requires laboratory suggestive evidence only. Possible (subclinical
cases) are often found when screening individuals for APSGN but do not present with
more than 1 clinical symptom. They do not have oedema or hypertension but on

15
 laboratory investigation are found to have haematuria, evidence of a streptococcal
infection and a reduced C3.

Laboratory definitive evidence

Renal biopsy suggestive of APSGN.
Laboratory suggestive evidence
a. Haematuria on microscopy (RBC >10/l). If microscopy is not available then moderate
haematuria on dipstick fulfils this criteria.
AND
b. Evidence of recent streptococcal infection (positive Group A Streptococcal culture from
skin or throat, or elevated ASO titre or Anti-DNase B). If all other criteria have been
fulfilled but the only evidence of recent streptococcal infection is isolation of Group C
or Group G Streptococci from skin or throat, this could be notified as a confirmed case
after discussion with infectious disease physician.
AND
c. Reduced C3 level
Clinical evidence
At least 2 of the following
facial oedema
moderate haematuria on dipstick
Hypertension (Hypertension as defined in CARPA Standard Treatment Manual)
peripheral oedema8

Simplified Classification of Hypertension for use in the CARPA STM 9

Systolic Diastolic Action

(mmHg) (mmHg)
<130 <85 normal BP, recheck in 12 years
130-139 85-89 high-normal BP, recheck in 1 year. Offer lifestyle
advice.
140-159 90-99 confirm within 2 months lifestyle advice
160-179 100-109 evaluate or refer within 1 month lifestyle advice
180 110 evaluate and refer within 1 week (or immediately
depending on

16
So, the patient can be included to the confirmed case. It obtained from laboratory
suggestive results which shows high titre of ASO, hypocomplementemia, and hematuria
from dipstick and from clinical evidence that is oedema on the both of eyelids, face and
legs, hematurian and hypertension.

The acute phase should be treated with antihypertensives, diuretics, salt restriction and
dialysis as necessary. If recovery is slow, corticosteroids may be helpful.4 Bed rest also
useful in acute phase treatment, but not in prolong time, usually 10-14 day.1 In this case, the
patient was given nifedipine as antihypertension, furosemide and aldactone as diuretics, and
had low salt nutrition.

APSGN can completely recover for 1-2 weeks if theres no complication, then it is often
clasified as self limiting disease. However , rarely APSGN can be relapse. In this case, the
pastient has discharge on the fouteenth days of hospitalized.

Generally, the course of this disease is marked by acute phase for 1-2 weeks, followed by
disappear of laboratory sign escpecially microscopic hematuria and proteinuria for 1-12
months. In child, 85-95% of APSGN case recover completely and 5-10% can be chronic
glomerulonephritis. Although, the prognosis is good, dead can occur in the acute phase as
acute kidney injury, acute pulmonary oedema, or hypertension ensefalophaty.1 In this case,
patient had dyspnoe which may shows symptom of pulmonary oedema.

SUMMARY

It has been reported a case of acute post streptococcal glomerulonephritis in a boy.

Evidence of APSGN is obtained from clinically and laboratoric result, that is oedema,
hypertension, hematuria, proteinuria, high titre of ASO, and hypocomplentemia. Treatment
were only bed rest, supportive, antihypertension, diuretics, and low salt nutrition. The
patient showed clinically improvement in 14 days treatment and has discharged on the
fourteenth days hospitalizing.

REFFERENCES

1. Rauf, S., Albar, H. & Aras, J., 2012. Konsensus Glomerulonefritis Akut Pasca
Streptokokus. In: Jakarta: Badan Penerbit Ikatan Dokter Anak Indonesia, pp. 1-21.
2. Branch, K., Hallingstad, D. A., Murphy, M. J. & Strauch, G., n.d. Alternations in
The Urinary System. In: Essentials of Pathophysiology: Concepts of Altered Health
States. Philadelpia: Lippincott, pp. 425-427.
3. Lewis, J. B. & Neilson, E. G., 2008. Glomerular Disease. In: Harrison's Principles
of Internal Medicine 17th Edition. New York: McGraw-Hill, pp. 1786-1790.

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4. Pardede, S. O., 2009. Struktur Sel Streptokokus dan Patogenesis Glomerulonefritis
Akut Pascastreptokokus. Sari Pediatri, Volume 11, pp. 56-65.
5. Kumar, P. & Clark, M., 2006. Glomerulopathies. In: Kumar and Clark Clinical
Medicine 6th Edition. London: Saunders.
6. Vincenti, F. G. & Amend, W. J. C., 2008. Diagnosis of Mediacal Renal Disease. In:
E. A. Tanagho & J. W. McAninch, eds. Smith's General Urology 17th Edition. New
York: McGraw-Hill, pp. 522-523.
7. GV, K., 2011. Clinical Study of Post Streptococcal Acute Glomerulonephritis in
Children with Special Refeerence to Presentation. Curr Pediatr Res, 11(2), pp. 89-
92.
8. Centre for Disease Control, 2010. Northern Territory Guidelines for Acute Post-
Streptococcal Glomerulonephritis 2010. Healthy Territory.
9. Boyden, A. et al., n.d. High Blood Pressure (Hypertension). Download from:
www.carpa.org.au

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