Case Presentation

Harold B. Briosos
Junior Intern
St. Paul University Philippines
School 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

Chief Complaint

Tea-colored urine

History of Present Illness

2 wks
PTA
(+) Vomiting 2x,
cup/bout
(+) Epigastric Pain
(+) Fever, 38c
(+) Dysuria
UTI
Paracetamol (13
mkd), Co-Amoxiclav
(40 mkd)

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

3 days
PTA

3 hours
PTA

Persistence of S/Sx
(+) tea-colored urine
(+) Periorbital edema
(+) consult
Referred, Admitted

Prenatal History

6x

FeSO4
Folate
MVS

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, Credes 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

5m 6m

7m

8m

10m

1st word
Mama, 6
1y months
Enters School
5 years

Immunization History

1 BCG
3 Hep B, DPT, OPV
1 Measles

Family History

Arthriti
s

Unremarkab
le

Review of Systems
(-) Seizure, (-)
Headache
(-) Pruritus
(-) Myalgia
(-) Loss of
Appetite

(-) diarrhea,
(-) constipation

(+) cough, (+)

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

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
Height:
Height: Measurements
115cm
115cm

Weight:
Weight: 19
19
BMI:
BMI: 14.9
14.9 kg
kg

 Height:
Height:

115cm
115cm
Weight:
Weight: 19
19
BMI:
BMI: 14.9
14.9 kg
kg

 Height:
Height:

115cm
115cm
Weight:
Weight: 19
19
BMI:
BMI: 14.9
14.9 kg
kg

Skin
(-) Pallor

(+)Healing skin

lesion
(-) Jaundice
(-) Rashes
(-) Cyanosis
Warm to touch

Right leg

HEENT
(-) Lesions, (-) Lumps
Anicteric sclerae, Pinkish

palpebral conjunctivae
(+) Periorbital edema
Visible cone of light, (-)

discharges
(-) Alar flaring, (-) discharges,

septum midline
(-) tonsillar hypertrophy, uvula

Mouth

(+) Dry lips

(-) Ulcers
Moist mucosa

Chest, Lungs and Heart

Symmetric chest expansion

(-) retractions, clear breath sounds
Adynamic precordium, PMI @ 4th

ICS LMCL, tachycardic,

rhythm, (-) Murmurs

regular

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

VIII: Good acuity to

whispered voice
IX, X: (+) Gag reflex

II, IV, VI: EOM intact

XI: Shrugs shoulders

V: (+) blink reflex

XII: Tongue at

VII: Symmetric face

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
RL

100
%
100
%

LU
LL

100
%
100
%

Deep Tendon Reflexes

Biceps Triceps Patella Achille

s
++
++
++
++

Meningeal Signs

(-) Kernigs sign

(-) Brudzinskis sign
(-) Nuchal Rigidity

Impression

Acute Post-streptococcal
Glomerulonephritis

Salient Features
Male
History of skin infection
Periorbital and facial

edema

(+) tea-colored urine

(+) dysuria
(+) fever

Differential
Diagnoses

IgA Nephropathy

Bergers 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

IgA Nephropathy

Rule In
Common in
males

Rule Out
(-) Recurrent episodes
of gross hematuria

(+) Hematuria

(-) Pain in the flank

(+)
Hypertension
(+) Fever

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
Hematuria
Hypertension

Rule Out
Onset: 2nd decade of
life
Recurrent episodes of
gross hematuriausually assoc. with
upper respiratory tract
infections.

Henoch-Schnlein
Purpura Nephritis
Most common small vessel

vasculitis in childhood.
Characterized by purpuric rash,

arthritis and abdominal pain.

Henoch-Schnlein
Purpura Nephritis
Rule In
Hematuria
(+) abdominal
pain

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

Course in the Ward

Day of Admission
Problems

Assessment

Intervention

BP: 120/90
(+) Periorbital
edema
Weight: 18kg

T/C Acute poststreptococcal

glomerulonephri
tis

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

Re-assessment

Problem Assesment
s
Hours after admission
BP:
T/C Acute post110/70
streptococcal
UO:
glomerulonephri
1cc/kg
tis

Intervention

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

Re-assessment
Problems
Assesment
Hours after admission
BP: 120/80
CR: 70
(+) Periorbital
edema

Intervention
Furosemide 1mkdose
repeat BP after 30
minutes
Strict I&O monitoring

Re-assessment
Problems
Assesment
Hours after admission
BP: 100/70
CR: 70
UO: 1cc/kg
(+) Periorbital
edema

Intervention
Furosemide
maintained at
1mkdose q 6
Strict I&O monitoring
Continue meds

Laboratory Findings

Serum Electrolytes
Sodium
Potassium
Chloride
WBC

146.7
3.90
113.7
9.5

Reference
Range
135-145
3.5-5.4
96-110
4.5-11.0

Laboratory Results
Urinalysis
Color
Transparency
Specific Gravity
Albumin, sugar, ketones,
bilirubin, urobilinogen, nitrite,
leukocytes
Blood
Leukocytes
Erythrocytes

straw
Clear
1.015
(-)

(+)
1-3
8-10

Laboratory Findings

Complete Blood Count

Hemoglobin
Hematocrit
Platelet count
WBC
Neutrophils
Lymphocytes

106
0.32
412
9.5
44.7
38.1

Reference
Range
135-180
0.40-0.54
150-400
4.5-11.0
35-65
20-40

Laboratory Findings

Clinical
Chemistry
Urea
2.31
Creatinine
43.3
Total Protein 77
Albumin
36
Globulin
41
A/G Ratio
.9

Range
2.5-7.10
53-115
63-82
35-50
23-35
1.5-2.5

Hematology
Result
ESR
80mm/h 0r
10
Serology Result
ASO
(+) 400

First Hospital Day

BP: 100/70
CR: 82
RR: 24
T: 36.8
UO: 2 cc/kg
Weight: 17kg
(-) Abd pain, (-)
Headache
(-) Nape pain, (-)
pallor

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

Cholesterol
Triglycerides
Direct HDLC
LDL

Norma
l
Range
4.2 mmol/L 0-5.17
1.27 mmol/L 0-1.69
.70 mmol/L 0-1.60
2.92 mmol/L 0-3.35

2nd Hospital Day

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

Assessme Intervention
nt
AGN
Strict I&O
monitoring
Furosemide IV
shifted to oral
PenG -> (50)
Amoxicillin
TID

Laboratory Findings

Clinical
Chemistry
C3
13.8 mg/dL

Normal
Range
90-180

3rd Hospital Day

Problem

Assessme
nt

Intervention

BP: 90/60
UO:
2.5cc/kg/hr
Wt: 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

Case Discussion
Acute Poststreptococcal Glomerulonephritis

Acute Poststreptococcal
Glomerulonephritis (APSGN)

Results from antecedent infection of

nephritogenic strains of Group A 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

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

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

patients
Recurrences are rare

in

95%

of

Prevention

Pneumococcal conjugate vaccine

children younger than 5 years old, all

adults 65 years or older.

Pneumococcal polysaccharide

vaccine
Adults 65 years or older

Thank you for

listening