Documente Academic
Documente Profesional
Documente Cultură
Poststreptococcal
Glomerulonephritis
Presentor: Jirran C. Cabatingan
Moderator: Dr. Warren Liongcheng
Reactor: Dr. Albert Lu
Objectives
To determine the cause of edema in a
44 y.o. female
To discuss diagnostic approach on
patient presenting with edema,
proteinuria and hematuria
To discuss management done on this
case
Identifying Data
L.N.
44 y.o.
Female
Catholic
Filipino
Caloocan City
Chief Complaint
Edema
Family History
(-) Hypertension
(-) Diabetes
(-) Renal problems
Personal History
(-) Smoker
(-) Alcoholic
(-) Allergies
Review of System
GUT: (-) urgency, (-) frequency, (-)
discharges
Physical Examination
Vital signs:
BP = 200/100mmHg (sitting)
CR = 89 BPM RR = 19 T =
36.7C
Weight = 69 Kg Height = 54
BMI =
Salient Features
Edema
Hematuria- tea colored urine
Hypertension
History of throat infection
Admitting Impression
Postinfectious Acute
Glomerulonephritis
probably Poststreptococcal
Approach to Edema
Edema
Generalized
(+)
Hypoalbuminemia
Localized
(-)
Hypoalbuminemia
If (-) Hypoalbuminemia
CHF
If (+) Hypoalbuminemia
Hepatic
Sever malnutrition
Renal
On Admission
IVF: PNSS 1L x KVO
Low salt, low fat die
Diagnostics
CBC
Urinalysis
Serum electrolytes, Crea, BUN
SGPT, TPAG
Therapeutics
Furosemide 80 mg IV now then 40
mg IV OD
Perindopril 10 mg tab, 1 tab now
then OD
Clonidine 75 mg tab, 1 tab TID
WBC
Neutrophil
10.0
0.63
Lymphocytes
0.26
Monocytes
0.10
Eosinophils
0.01
Basophils
0.00
Hemoglobin
122
Hematocrit
0.37
RBC
4.8
MCV
78.1
MCH
25.5
MCHC
327
RDW
13.5
Platelet
305
MPV
7.7
Urinalysis
Color
Amber
Transparency
Turbid
Specific Gravity
1.025
pH
6.0
RBC
TNTC
PUS
30-35/HPF
Bacteria
+2
Protein
+3
Epithelial Cells
Few
Leukocytes
+3
Blood
+3
Total protein
Albumin
Globulin
A/G ratio
Creatinine
6.61
3.16
3.45
9:10
38.70
BUN
85.80
Potassium
3.27
Sodium
141
6.60-8.70
3.97-4.94
2.63-3.76
45.00-84.00
umol/L
2.14-7.14
mmol/L
3.50-5.10
mmol/L
136-145
mmol/L
Day 1
S
Problem
Edema
(+)
Periorbital
edema
Hematuria
No rales
(tea-colored, No neck
foamy)
vein
distention
Elevated BP No
costoverteb
ral
tenderness
(+) bipedal
edema, gr.
1
(+) macular
rash both
legs
BP 190/100
Poststreptococc
al
GN
ASO titer
Urine RBC
morphology
Phenoxymet
hylpenicillin
(Sumapen)
500mg cap,
1 cap q 6H
Furosemide
40 mg IV
OD
Perindopril
10 mg OD
Clonidine 75
mg BID
Total Cholesterol
Triglyceride
HDL Cholesterol
LDL Cholesterol
FBS
181.47 mg/dL
96.25 mg/dL
29.34 mg/dL
132.82 mg/dL
123.08 mg/dL
Urinalysis
RBC
PUS
Protein
Remarks
HBsAG
ASO Titer
10-15
1-3
+2
Some RBCs are
crenated
Non-Reactive
Negative
ECG Interpretation
Sinus Tachycardia
Left Ventricular Hyperthropy
Day 2
S
Problem
Edema
Periorbital
and bipedal
edema
reduced
No rales
No neck
vein
distention
Acute
PostStreptococcal
GN
Nephrotic
syndrome
Phenoxymet
hylpenicillin
(Sumapen)
500 mg cap,
1 cap q 6H
Furosemide
40 mg IV
OD
Perindopril
10 mg tab
OD
Clonidine
150 mg tab
BID from 75
mg tab
Hematuria
(less)
Elevated BP
BP 180/100
HR 74
RR 18
I 1320
O 2700 (1380)
Day 3 to 4
S
Problem
Elevated BP
No neck
vein
engorgeme
nt
No rales
Full pulses
on all
extremities
No motor
weakness
PostStreptococc
al GN
Nephrotic
syndrome
Phenoxymet
hylpenicillin
(Sumapen)
500 mg cap,
q 6H
Furosemide
discontinue
d
Repeat CBC,
serum
electrolytes,
creatinine
and
urinalysis
No edema
No Hematuria
BP 120/80
-150/90
HR 88
RR 19
I 2350
O 1360 (990)
Creatinine
43.50
Potassium
3.24
Sodium
140
ANA
Negative
45.00-84.00
umol/L
3.50-5.10
mmol/L
136-145
mmol/L
C3/Complement
3
Random Urine
Protein
Random Urine
Creatinine
Protein/Creatinin
e Ratio
SGPT
ANA
<400 mg/L
880-1650
462 mg/L
10-140
0.55 mmol/L
2.55-20
0-33
RBC
PUS
Protein
Leukocytes
Blood
15-20
8-10
+2
+1
+2
S
Hypokalemi
a
P
K lyte tab,
1 tab TID
for 2 days
Day 5
S
No subjective
complaints
No rales
No neck
vein
distention
PostStreptococc
al GN
Nephrotic
Syndrome
Plan for
discharge
Home
Medications
:
1. Perindopril
10 mg tab,
1 tab OD
2. Felodipine
10 mg tab,
1 tab OD
3. Clonidine
150 mcg
tab, 1 tab
BID
No edema
No hematuria
BP 120/70
140/70
HR 74
RR 18
I 1740
O 1340
4. Sumapen
500 mg cap, 1
cap q 6H to
complete 10
days of
treatment
5. K lyte tab, 1
tab TID x 1
more day
Advised for
follow up
after a week
with repeat
CBC, serum
electroltes,
urinalysis
Final Diagnosis
Acute Poststreptococcal
Glomerulonephritis
Poststreptococcal
Glomerulonephritis
Post streptococcal
glomerulonephritis (PSGN) is
caused by prior infection with
specific nephritogenic strains
of group A beta-hemolytic
streptococcus.
Epidemiology
Although PSGN continues to be
the most common cause of
acute nephritis globally, it
primarily occurs in developing
countries
In more developed and
industrialized countries, the
incidence has decreased over
the past three decades.
Pathogenesis
PSGN appears to be caused by
glomerular immune complex disease
induced by specific nephritogenic
strains of group A beta-hemolytic
streptococcus (GAS).
The resulting glomerular immune
complex disease triggers
complement activation and
inflammation.
Nephrotogenic Anigens
1. Nephritis-associated plasmin
receptor (NAPlr), a glycolytic
enzyme, which has glyceraldehyde3-phosphate dehydrogenase
(GAPDH) activity
2. Streptococcal pyrogenic exotoxin B
(SPE B), a cationic
cysteineproteinase
Pathologic Changes
Light microscopic findings
Early stage glomerular
hypercellularity
Later stage Proliferation of
intrinsic endothelial &
mesangial cells
Immunofluorescence Microscopy
Coarse granular staining for IgG
& C3 can be detected in GCW
IgM less frequently
IgA & C1 & C4 absent
Garland , starry sky & mesangial
patterns
Electron Microscopy
The dome-shaped
subepithelial electron-dense
deposits that are referred to
as humps.
Clinical Presentation
There is usually an
antecedent history of a group
A beta-hemolytic
streptococcal (GAS) skin or
throat infection.
Latent period (1-2 wks,
throat infection , 3-6 wks skin
infection)
Laboratory Findings
Urinalysis
Heamaturia with dysmorphic
RBCs
Proteinuria mostly are in the
subnephrotic range, 20% are
nephrotic range (>3.5 g/24)
which is more in adults
Complement
In about 90 percent of patients,
C3 and CH50 (total complement
activity) are significantly
depressed in the first two
weeks of the disease course.
The C3 and CH 50 return to
normal within four to eight
weeks after presentation.
Culture
about 25 percent of patients
will have either a positive
throat or skin culture.
In patients with impetigo,
there is an increased
likelihood of obtaining a
positive skin culture.
Serology
Anti-streptolysin (ASO)
Anti-hyaluronidase (AHase)
Anti-streptokinase (ASKase)
Anti-nicotinamide-adenine
dinucleotidase (anti-NAD)
Anti-DNAse B antibodies
Diagnostic Evaluation
The clinical findings of acute
nephritis include hematuria with
or without red blood cell casts,
variable degrees of proteinuria,
edema, and hypertension.
Documentation of a recent GAS
infection includes either a
positive throat or skin culture or
serologic tests (eg, ASO or
streptozyme test).
Diagnostic Evaluation
U/A: dysmorphic or crenated RBCs & RBC casts
Proteinuria (5-10% nephrotic range)
WBC, hyaline & granular casts
BUN , Cr
ASO , Anti- NADase (80% postpharyngitis
nephritis)
Antihyaluronidase & Anti- DNase B (80-90%)
skin infections)
Antibody titers 1-5 wks after infections
C3, C4 , CH50
C3 , CH50(90%)
ANCA (9%)