ACUTE GLOMERULONEPHRITIS

CASE PRESENTATION

General Objective
To present a case of Acute Glomerulonephritis

Specific Objectives
To discuss Acute Glomerulonephritis as to

definition, etiology, epidemiology, and pathophysiology To generate appropriate differential diagnosis To recognize the typical clinical manifestations To provide the proper management and prognosis of the disease

GENERAL DATA
J.R.N., 5 years old, EDS Roman Catholic Born on June 18, 2002 1st time admission on March 1, 2008

CHIEF COMPLAINT:

abdominal distention

History of Present Illness

1 month PTA pyodermal lesions on both legs no asstd signs & symptoms (-) consult self-medicated with Penicillin warm, erythematous, pruritic lesions were noted on the left leg No asstd signs & symptoms (-) consult liniments lesions spread to trunk and extremities (+) abdominal pain no consult done nor medications taken

10 days PTA

9 days PTA

8 days PTA

7 days PTA
5 days PTA

(+) facial and periorbital edema (-) changes in urine color and frequency self-medicated with Dicycloverine 5ml q6 hours x 2 days (+)Facial and periorbital edema receding edema persisted now associated with abdominal distention No consult nor medications

1 day PTA

Few hours PTA

(+) abdominal distention, puffy eyelids and facial edema (+) bipedal edema (-) change in color of the urine Consult: Fort Magsaysay Station Hospital (-) laboratory examinations Dx: Allergic Reaction Meds:Chlorphenamine maleate 2mg/5ml, 5ml TID (+) abdominal pain persistence of symptoms consult: private physician Dx: Acute Glomerulonephritis Urinalysis
Color Amber Transparency turbid Reaction 5.0 Sp. Gravity 1.015 Sugar Protein +4 RBC plenty Pus cells 80-90

transferred to our institution

admitted

PRENATAL Hx:
Cognizant at 1 month AOG

regular PNCU at public hospital in Cabanatuan City

regular intake of multivitamins and ferrous

sulfate denies any exposure to radiation, infections, communicable diseases, intake of teratogenic drugs

NATAL Hx:
born to a 29 y/o G5P5 (5005), FT

delivered via NSD at Fort Magsaysay

BW of 2.7kg good cry and activity no fetomaternal complications noted

FEEDING Hx:
Birth 1 mos old pure

breastfeeding

1mos 6 mos - BONNA 6mos 16 mos pure breastfeeding 16mos - present Bear brand weaning - 7 months solid foods at 10 months At present - 1 cup of rice per meal and prefers to eat hotdog, salted fish. Drinks 12 glasses of milk formula (Bearbrand) per day

IMMUNIZATION
BCG
OPV3 DPT3

Measles

*local health center

GROWTH AND DEVELOPMENT

-

Gross motor Can ride a tricycle, jump Fine motor Imitate a circle and draw lines, can write name Language Can count 1-10, can identify colors Personal/social Plays interactive games, washes and dries hand

PAST MEDICAL Hx
8 mos old admitted for 5 days at PJN

(Cabanatuan City) due to Bronchopnuemonia 2-3 episodes of cough and colds a year lasting for 5-7 days no allergy to foods and drugs no childhood diseases noted

FAMILY Hx:
Father- 40 y/o, soldier Mother- 35 y/o, housewife Siblings 1- 16 y/o, female 2- 14y/o, female 3- 11y/o, female 4- 8y/o, male

5- index patient 6- 4y/o, male (+) DM and (+) HPN maternal grandfather (+) bladder stone maternal grandfather (+) BA maternal uncle (+) kidney diseases maternal cousins (-) malignancy, PTB

PERSONAL AND SOCIAL Hx:

5th of 6 siblings lives with 8 other household members bungalow type of house with 3 BR and 2 CR Mother primary caregiver Water source - deep well Garbage - disposed properly

REVIEW OF SYSTEMS:
Constitutional: (-) fever, (-) weakness HEENT: (-) blurring of vision, (-) sore

throat, (-) nasal obstruction Respiratory: (-) hemoptysis, (-) shortness of breath GIT: (-) vomiting, (-) constipation, (-) diarrhea GUT: (-) dysuria, (-) urethral discharge NS: (-) headache, (-) LOC, (-) numbness Extremities: (-) stiffness of joints

PHYSICAL EXAMINATION:
General Survey: conscious, coherent, ambulatory, afebrile, not in distress Vital Signs: BP- 150/100 CR- 98 RR- 32 T- 36.80C Anthropometrics: Wt 20 kg (p75) IBW 18 kg Ht 106 cm (p25) IBH 112 cm G - 111% S - 94.6% W - 114.3%

Skin: warm, moist, good skin turgor and elasticity, CRT < 2sec HEENT: pink palpebral conjunctivae, anicteric sclera, intact tympanic membrane AU, no nasoaural discharge, no tonsillopharyngeal congestion, (+) facial edema, (+) puffy eyelids

Neck: supple, no palpable lymph nodes

Chest/Lungs: symmetrical chest expansion, clear breath sounds, no retractions, good air entry Heart: adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: distended, slit-like umbilicus, AC = 52cm, soft, non-tender, no organomegaly, (-) fluid wave Extremities: no gross deformities, full and equal pulses, bipedal edema, (+) healed pyodermal lesions, no cyanosis

ASSESSMENT:

Acute Glomerulonephritis prob Post Streptococcal Glomerulonephritis

Salient Features:
5 years old, male History of pyodermal lesions

PE: Abdominal pain and distention Edema periorbital, bipedal Slit like umbilicus Hypertension

Laboratory: - Urinalysis Hematuria (microscopic) Proteinuria Pyuria

COURSE IN THE WARDS:

Upon admission Laboratory examinations

Color: dark yellow Transparency : turbid Reaction: 6.0 Sp. Gravity: 1.010 Sugar: Protein: +3 RBC: 20-30 Pus cells: 40-50

Urinalysis C3, ASO CBC Serum electrolytes BUN, Crea TPAG KUB UTZ

TP 55.5 Albumin 26.4 Globulin 27.1

Therapeutics

Furosemide 1mkdose Pen G 100,000 u/kg/day Nifedipine 5mg prn for BP >120/80

Hgb Hct RBC WBC Plt count S L E

110 0.33 4.31 19.9 313 0.58 0.28 0.14

ASO negative

Na 142.9 K 5.14 Cl 116.9 Crea 40.3

1st
S>

hospital day

with hypertensive episodes abdominal pain O > conscious, ambulatory BP 150-120/80-90 CR 80-88 bpm cpm Temp 36.5-37.10C slit like umbilicus, AC = 52cm bipedal edema facial edema A > AGN prob PSGN P > HL Meds: Pen G 100,000u/kg/day Furosemide q12H

RR 20

2nd

hospital day
S/O > (+) facial and bipedal edema (-) abdominal pain BP 110-130/70-100 AC = 51 cm (52cm) Adequate urine output (1.6 cc/kg/hr) A> AGN prob PSGN P> Oral fluid intake limited to 190ml qshift Furosemide 1mkdose q12 hours Pen G continued - receding

3rd hospital day

S/O > (+) episodes of hypertension (-) facial edema (-) bipedal edema AC = 46cm (51) A> AGN prob PSGN P> Nifedipine was discontinued Furosemide q8H shifted to q6H with BP precautions

5th hospital day

S/O > (-) edema (-) hypertensive episodes adequate urine output A> PSGN P> For repeat urinalysis Furosemide to q8hrs Pen G D5

C3 430mg/L

Color Amber Transparency turbid Reaction 6.0 Sp. Gravity 1.015 Sugar Protein RBC TNTC Pus cells 0-2

6th

hospital day
S/O > (-) hypertensive episodes (-) edema (-) abdominal pain A> PSGN P> Pen G IV shifted to Sumapen 250mg/5ml, 6.5 ml q6H referral to Pedia Nephrologist (Furosemide q8H then taper)

9th hospital day

S/O > AC = 45cm wt = 16.2 kg adequate urine output stable vital signs A> PSGN P> Furosemide discontinued Home meds:
Sumapen 250mg/5ml, 6.5 ml q6H x 4 days MV syrup, 1 tsp OD

KUB UTZ (3/12/08)

Final Diagnosis:
Post Streptococcal Glomerulonephritis

DISCUSSION

ACUTE GLOMERULONEPHRITIS
- Usually signifies an inflammatory process causing renal dysfunction over days to weeks that may or may not resolve

Currents, 2003

 Sudden onset of gross hematuria, edema, hypertension, and renal insufficiency One of the most common glomerular causes of gross hematuria in children

Nelsons, 17th ed

Etiology
Streptococcal pharyngitis (serotype 12) cold

weather months Streptococcal skin infections or pyoderma (serotype 49) warm weather months

Textbook of Pediatrics and Child Health, 4th ed

Epidemiology
Post -infectious type most common

most common in males (1.7 -2:1) ages 6 to 10 but can occur at any age

Handbook of Diseases, Copyright 2003

Pathophysiology
pyodermal lesions
OLIGURIC PHASE Inc ASO, antistreptokinase

Ag-Ab complex
decrease C3 Ag-Ab complement complex

Autoimmune/inflam rxn in glomerulus

Na, water balance

Edema, HPN, CHF

ECF expansion DIURETIC PHASE CONVALESCENT PHASE

Clinical Manifestations

Hematuria Proteinuria Edema Hypertension Oliguria Nonspecific symptoms Abdominal pain Malaise Fever

Stages
- typical course lasts 7-10 days for each of

the 3 phases
Oliguric phase acute salt and water

overload
Diuretic phase BP normalizes Convalescent phase

Diagnosis
Urinalysis
CBC Blood chemistries C3, ASO Renal biopsy

Complications
Acute Renal Failure

Hypertensive encephalopathy
Congestive Heart failure

Treatment
Supportive

Diet low Na, low protein

Activity Medications Antibiotic Penicillin, Erythromycin Anti-hypertensive drugs Furosemide,

vasodilators, ACEI

Prognosis
More than 95% of affected children eventually recover totally with conservative therapy aimed at maintaining sodium and water balance.

Robbins, Pathologic Dses, 6th ed

Follow-up Care
Proper education about patients condition

Ff-up every 2 weeks with urinalysis result

8-10 weeks after onset C3 determination 12 mos after onset serum Crea in normal level

SUMMARY

Thank You!