Case Presentation

General data
Patient R.Q.
6 years old
Male
Filipino
Penablanca, Cagayan
Roman Catholic
Born on November 8, 2012
Date of admission: April 22, 2019
Source of information: Mother (95%
reliability)
Chief complaint:

Tea colored urine

Chief complaint:

Tea colored urine

History of Present Illness

9 days PTA
• Undocumented
fever
• cough
• No other associated
signs and symptoms
• Paracetamol given
(13 mkdose)
• No consult done
History of Present Illness

9 days PTA 8 days PTA

• Undocumented • Noted swelling of
fever left submandibular
• No other associated area
signs and symptoms • Undocumented
• Paracetamol given fever
(13 mkdose) • Paracetamol
• No consult done (13mkdose)
• No consult
History of Present Illness

9 days PTA 8 days PTA

• Undocumented • Noted swelling of
fever left submandibular
• No other associated area
signs and symptoms • Undocumented
• Paracetamol given fever
(13 mkdose) • Paracetamol
• No consult done (13mkdose)
• No consult
History of Present Illness

9 days PTA 8 days PTA 7 days PTA

• Undocumented • Noted swelling of • Noted bilateral
fever left submandibular swelling of
• Paracetamol given area submandibular
(13 mkdose) • Undocumented area
• No consult done fever Undocumented
fever
• Paracetamol
(13mkdose) • Paracetamol
(13mkdose)
• No consult
• No consult
History of Present Illness

Interval
history
• intermittent fever
History of Present Illness

Interval 2 days PTA

history • Decreased urine
• Intermittent fever output approx. < 1
cup/24 hours
• No consult done
History of Present Illness

Interval 2 days PTA 1 day PTA

history • Decreased urine • Decreased urine
• Intermittent fever output approx. < 1 output approx. < 1
cup/24 hours cup/24 hours
• No consult done • Undocumented
fever
• Tea colored urine
• Facial and
periorbital edema
• No consult done
History of Present Illness

FHPTA
• Persistence of s/sx
• Prompted consult at
PMD
History of Present Illness

FHPTA CBC
• Persistence of s/sx Hgb: 95 g/L WBC: 20.3
• Prompted consult at Hct: 30.5% N: 87.7
PMD
Platelets: 343 L: 9.7
M: 2.6

Urinalysis
Amber 5 ++++ TNTC
Cloudy 1.015 - TNTC
History of Present Illness

FHPTA CBC Hence

Hgb: 95 g/L WBC: 20.3
• Periorbital edema Hct: 30.5% N: 87.7 referred to
• Undocumented Platelets: 343 L: 9.7
our institution
fever M: 2.6
• Facial swelling
for further
Urinalysis
• Decreased urine evaluation and
output Amber 5 ++++ TNTC management
• Prompted consult at
Cloudy 1.015 - TNTC
PMD
Past Medical History

No previous hospitalization
No known allergies to food and drugs
Neonatal History

Antenatal
history
• More than 5
PNCU at LHC
• MVS, Ferrous
sulfate
• No medical
conditions/illness
es during
pregnancy
• Mother is non
smoker, non
alcoholic drinker
Neonatal History

Antenatal Natal history

history • G1P1 (1001)
• More than 5 • 23 year old
PNCU at LHC mother
• MVS, Ferrous • Cephalic
sulfate
• Forceps delivery
• No medical
conditions/illness • BW: 3.45 kg
es during • No other
pregnancy complications
• Mother is non noted
smoker, non
alcoholic drinker
Neonatal History

Antenatal Natal history Post Natal

history • G1P1 (1001)
history
• More than 5 • 23 year old
PNCU at LHC mother • Noted with good
• MVS, Ferrous • Cephalic cry and good
sulfate
• Forceps delivery suck
• No medical
conditions/illness • BW: 3.45 kg
es during • No other
pregnancy complications
• Mother is non noted
smoker, non
alcoholic drinker
Immunization History

•Care of LHC
•BCG: 1
•Hepa B: 1
•OPV: 3
•DPT: 1
•Measles: 1
Nutritional History

•Purely breastfed until 7 months of age,

complementary food was then introduced
•Present diet includes rice, meat, fruits and
vegetables.
Developmental History

•1st word: Mama at 8 mos

•Toilet-trained: 3 years old
•Entered kindergarten: 5 years old
•Entered gradeschool:
Nutritional History

•Purely breastfed until 7 months of age,

complementary food was then introduced
•Present diet includes rice, meat, fruits and
vegetables.
Personal and Social History
• Only child
• Lives with parents: father 31 year old contractual worker, mother 29 year old
housewife
• Wooden house
• Source of drinking water: NAWASA
• Incoming grade 1 student
Family History
• (+) hypertension: maternal side
• (-) renal disease
• (-) heart disease
• (-) DM
• (-) asthma
Review of Systems
Skin No skin lesions

HEENT No dysphagia, no colds

Cardiopulmonary No cough, no chest pain, no difficulty of breathing, no easy fatigability

Gastrointestinal No diarrhea, no vomiting

Neurologic No seizure

Musculoskeletal No joint pains

Hematologic No bleeding gums

Genitourinary No dysuria
Physical Examination

General appearance Patient is awake, conscious and coherent, lying in bed,

comfortable, not in distress
Vital signs BP: 110/80
90th:166/68
98th: 110/72
99th: 117/80
CR: 113

RR: 20

T: 36.5

Wt: 19.5 kg

Ht: 109 cm
Physical Examinatioin
Skin No pallor, warm to touch, good skin turgor

HEENT Normocephalic head, anicteric sclerae, pink palpebral

conjunctiva, (+) periorbital edema, (+) facial edema, (-)
tonsillopharyngeal congestion
Chest and Lungs Symmetrical chest expansion, clear breath sounds, no retractions

Heart Adynamic precordium, normal rate regular rhythm, PMI at 5th

intercostal space midclavicular line, (-)murmur
Abdomen Flat, normoactive bowel sounds, soft, non tender

Genitourinary Grossly male, no genital edema

Extremities No deformities, no bipedal edema, full and equal pulses

9 days PTA
• Undocumented fever
• Paracetamol given (13
mkdose)
• No consult done
8 days PTA 7 days PTA
• Noted swelling of left • Noted bilateral swelling of
submandibular area submandibular area
described by mother as
• Undocumented fever mumps
• Undocumented fever
• Paracetamol
(13mkdose) • Paracetamol (13mkdose)
• No consult
• No consult

Interval 2 days PTA 1 day PTA

• Decreased urine • Decreased urine output
history output approx. < 1 approx. < 1 cup/24 hours
cup/24 hours • Undocumented fever
• Intermittent fever
• Undocumented fever • Tea colored urine
• Increased facial • No consult done
swelling • No consult done

FHPTA CBC Urinalysis

• Periorbital edema Hgb: 95 g/L WBC: 20.3
• Undocumented fever Hct: 30.5% N: 87.7 Amber 5 ++++ TNTC
• Facial swelling Platelets: 343 L: 9.7
• Decreased urine output M: 2.6 Cloudy 1.015 - TNTC
• Prompted consult at PMD
Salient features:
• 6 year old
• Male
• History of intermittent fever for 9 days
• Facial swelling
• Periorbital swelling
• Decreased urine output approx. <1cup/24 hr
• Tea colored urine
• No history of ATP
• No history of pyodermal lesions
• Protein UA: ++++
Differential Diagnosis
Congestive heart failure

Rule in Rule out

Facial/periorbital edema No bipedal edema
No easy fatigability
No exercise intolerance
No dyspnea
No cough
No orthopnea
Nephrotic syndrome

Rule in Rule out

More common in Male No hypertension
than Female (2:1) No generalized edema
Common in ages 2-6 No foamy urine
years old
Facial/periorbital edema
Hypersensitivity reaction

Rule in Rule out

Facial/periorbital edema No known allergies to
food or medications
No pruritus
No skin lesions
Acute glomerulonephritis

Rule in Rule out

Hypertension No history of ATP
Facial/periorbital edema No history of pyodermal
Decreased urine output lesions
Tea colored urine
Course in the ward: Admission
S O A P

(+) tea- BP: 110/80 CR: 113 SO2: 99% Acute Admitted
colored 90th : 116/68 T: 36.5 RR: 20 Glomerulonep Diet: low salt, low fat
urine hritis
(+) 95th: 110/72
99th: 117/80 Heplock
decreased
frequency in
urination Diagnostics: CBC, SE,
Skin No pallor, warm to touch, good skin turgor
Creatinine, BUN, ASO, C3,
HEENT Normocephalic head, anicteric sclerae, pink UA with RBC morphology
palpebral conjunctiva, (+) periorbital edema, (+)
facial edema, (-) tonsillopharyngeal congestion
Treatment: Furosemide 1
Chest and Symmetrical chest expansion, clear breath kdose q 6
Lungs sounds, no retractions
Penicillin G 100, 000
Heart Adynamic precordium, normal rate regular IU/kg/day
rhythm, PMI at 5th intercostal space midclavicular
line, (-)murmur
Limit OFI 500/BSA
Abdomen Flat, normoactive bowel sounds, soft, non tender
Monitor I and O
Genitourinary Grossly male, no genital edema

Extremities No deformities, no bipedal edema, full and equal

pulses
Course in the ward: Admission (4/22)
CBC Urea: 20.9mmol/L
Hgb: 101 g/L WBC: 25.23 Crea: 137.5umol/L
Hct: .301 N: 76.8
Platelets: 393 L: 15.5 UA RBC morphology
M: 5.2
Normal RBC: 80%
E:2.1
B: 0.4 Dysmorphic RBC: 20%

Na: 126.8mmol/L K:3.55mmol/L

Cl: 92.7mmol/L
Urinalysis
Dark 6 ++ Blood:
yellow +++
Hazy 1.025 - WBC: ++
Course in the ward: 1st HD
S O A P

(-) fever BP: 100/70 CR: 94 SO2: 98% Acute Diet: low salt, low fat
(-) headache T: 37.5 RR: 24 Glomerulonep
(-)abdominal hritis Heplock
pain UO: 1.81 cc/kg/hr
Skin No pallor, warm to touch, good skin turgor Treatment: Furosemide
(-)vomiting
20 mg/IV q6
HEENT Normocephalic head, anicteric sclerae, pink (100) Penicillin G 500 000
palpebral conjunctiva, (+) periorbital edema, (+)
IU/IV q6
facial edema, (-) tonsillopharyngeal congestion

VS Q2
Chest and Symmetrical chest expansion, clear breath
Lungs sounds, no retractions I and O qshift
WOF: untoward s/sx
Heart Adynamic precordium, normal rate regular Refer
rhythm, PMI at 5th intercostal space midclavicular
line, (-)murmur

Abdomen Flat, normoactive bowel sounds, soft, non tender

Genitourinary Grossly male, no genital edema

Extremities No deformities, no bipedal edema, full and equal

pulses
Course in the ward: 1st HD (4/23)

ASO: 400 IU/ml

Course in the ward: 2nd HD (4/24)
S O A P

(-) fever BP: 90/60 CR: 98 SO2: 98% Acute Diet: low salt, low fat
(-) headache T: 36.8 RR: 24 Glomerulonep
(-)abdominal hritis Heplock
pain UO: 2.3 cc/kg/hr
Skin No pallor, warm to touch, good skin turgor Treatment:
(-)vomiting
(+)adequate Furosemide decreased to
urine output HEENT Normocephalic head, anicteric sclerae, pink q8
palpebral conjunctiva, decreased periorbital
edema, decreased facial edema, (-)
tonsillopharyngeal congestion Continue meds and
management
Chest and Symmetrical chest expansion, clear breath
Lungs sounds, no retractions

Heart Adynamic precordium, normal rate regular

rhythm, PMI at 5th intercostal space midclavicular
line, (-)murmur

Abdomen Flat, normoactive bowel sounds, soft, non tender

Genitourinary Grossly male, no genital edema

Extremities No deformities, no bipedal edema, full and equal

pulses
Course in the ward: 2nd HD (4/24)
C3: 0.246 g/L
Course in the ward: 3rd HD (4/25)
S O A P

(-) fever BP: 90/60 CR: 95 SO2: 99% Acute Diet: low salt, low fat
(-) headache T: 36.8 RR: 22 Glomerulonep
(-)abdominal hritis Heplock
pain UO: 2.3 cc/kg/hr
Skin No pallor, warm to touch, good skin turgor Treatment:
(-)vomiting
Shift IV furosemide to
HEENT Normocephalic head, anicteric sclerae, pink Oral
palpebral conjunctiva, no periorbital edema, no
facial edema, (-) tonsillopharyngeal congestion
VS Q2
I and O qshift
Chest and Symmetrical chest expansion, clear breath
Lungs sounds, no retractions WOF: untoward s/sx
Refer
Heart Adynamic precordium, normal rate regular
rhythm, PMI at 5th intercostal space midclavicular
line, (-)murmur

Abdomen Flat, normoactive bowel sounds, soft, non tender

Genitourinary Grossly male, no genital edema

Extremities No deformities, no bipedal edema, full and equal

pulses
Course in the ward: 4th HD (4/26)
S O A P

(-) fever BP: 90/60 CR: 95 SO2: 98% Acute MGH

(-) headache T: 36.8 RR: 22 Glomerulonep Home meds:
(-)abdominal hritis Amoxicillin 40 mkday to
pain UO: 2.3 cc/kg/hr
Skin No pallor, warm to touch, good skin turgor complete 6 days more
(-)vomiting

HEENT Normocephalic head, anicteric sclerae, pink Daily BP monitoring at

palpebral conjunctiva, (+) periorbital edema, (+)
home
facial edema, (-) tonsillopharyngeal congestion
Bring monitoring sheet
on follow up
Chest and Symmetrical chest expansion, clear breath
Lungs sounds, no retractions Low salt, low fat diet
TCB on April 30 8am at
Heart Adynamic precordium, normal rate regular Pedia OPD
rhythm, PMI at 5th intercostal space midclavicular
line, (-)murmur Advised

Abdomen Flat, normoactive bowel sounds, soft, non tender

Genitourinary Grossly male, no genital edema

Extremities No deformities, no bipedal edema, full and equal

pulses
 Kidneys

• Retroperitoneally located
• Functional unit: nephron
Kidneys
Kidneys
Functions of the kidneys:
1. Homeostasis
2. Hematopoietic function
3. Endocrine function
4. Regulation of BP
5. Regulation of Blood Ca levels
Glomerulonephritis

• Glomerular injury
with evidence of
proliferation and
inflammation of
glomerulus such as
leukocyte
infiltration, antibody
deposition and
complement
activation
Acute Post-Streptococcal
Glomerulonephritis
• PSAGN is due to prior infection
with the nephritogenic strains of
Group A beta-hemolytic
streptococci.
• The most consistent strains
reported or demonstrated in
earlier studies are:
• M-type 12 for pharyngitis related
• M-type 49 for pyoderma-related
attacks.
Acute Post-Streptococcal
Glomerulonephritis
• most common in children ages
5-12 yr and uncommon before
the age of 3 yr
• typical patient develops an
acute nephritic syndrome
• 1-2 wk after an antecedent
streptococcal pharyngitis
• 3-6 wk after a streptococcal
pyoderma
Acute Post-Streptococcal
Glomerulonephritis
Acute Post-Streptococcal
Glomerulonephritis
• Classic example of acute
nephritic syndrome
characterized by sudden onset
of:
• Gross hematuria
• Edema
• Hypertension
• Renal insufficiency
Acute Post-Streptococcal Glomerulonephritis

Clinical manifestations

Gross hematuria Edema Hypertension Renal insufficiency

Rust/ tea/cola colored Swelling/ edema: usually mild to oliguria: UO < 400 ml/day
urine or hematuria • Eyes moderate
• face
• feet,
ankles,
hands
• abdomen

non specific symptoms: • Shortness of breath

• fever or dyspnea • Anorexia
• nausea • flank pain • Skin pallor
• Headache • Abdominal pain • malaise
Acute Post-Streptococcal Glomerulonephritis
Streptococcal
infection

Production of
antibodies

Antibody
complexes
circulate

Complex deposit in
the glomerular
tissue
 Streptococcal infection
Production of antibodies

Antibody complexes circulate

Complex deposit in the glomerular

tissue

Recruitment of WBC, platelets,

activation of complement system

Injury to glomerular wall

and filtration barrier
 Streptococcal infection Injury to glomerular wall and
filtration barrier
Production of antibodies

Proteinuria
Antibody complexes circulate Passage of RBC,
WBC into urine

Obstruction of glomerular
Complex deposit in the capillary lumen and intrarenal
glomerular tissue vasoconstriction

Recruitment of WBC,
platelets, activation of
complement system
 Injury to glomerular wall and
filtration barrier

Proteinuria Passage of RBC,

Obstruction of WBC into urine
glomerular capillary
lumen and intrarenal
vasoconstriction
Decrease Plasma
oncotic pressure Hematuria, RBC
Decrease GFR casts, dysmorphic
RBCs, Pyuria

Edema Oliguria Increase Renin

Increase BUN Decrease Na Increase

Angiotensin/Aldosterone Na retention
and Creatinine excretion

Water retention

Hypertension
 Clinical course

Latent period Oliguric phase Diuretic Phase Early

• Gross ↓ GFR: • Spontaneous convalescence
• hematuria • oliguria voiding • Improved well
• Edema • azotemia • Gross being
• Hypertension • fluid & salt hematuria
• Oliguria retention starts to
• Hematuria, • edema, improve
• proteinuria, • hypertension • BP normalizes
• cylinduria • Complications: • Problem:
• Labs: -Renal failure Unrecognized
• Anemia -Hypertensive hypovolemia
• ↓C3 encephalopathy
• - ASO -CHF
• ↓ Na+
 Clinical course

• acute phase generally resolves within 6-

8 wks
• urinary protein excretion and
hypertension usually normalize by 4-6
wks after onset
• persistent microscopic hematuria can
persist for 1-2 yr after the initial
presentation.
 Laboratory Result
Examination
Urinalysis with RBC May demonstrate RBCs, RBC casts, Proteinuria, PMNs, or dysmorphic
morphology RBCs particularly acanthocytes

CBC Mild normochromic anemia may be present from hemodilution and

low grade hemolysis
Serum C3 Reduced in acute phase and returns to normal 6 to 8 wks after onset
ASO Titer Increased after pharyngeal infection rarely increases in strep skin
infection
Anti-Dnase B Documents Recent Strep Skin infection
Serum Electrolytes To correct any electrolyte abnormalities
BUN and Creatinine Renal function tests
Chest X-ray Pulmonary Edema
Renal Biopsy Persistent microscopic hematuria
Children with recurrent gross hematuria with dec. renal function,
proteinuria or HTN.
 Treament

• Treatment is directed in treating the acute

effect of renal insufficiency and hypertension.
-Treatment of hypertension:
> sodium restriction
> diuresis
> calcium channel antagonist vasodilator
> ACE inhibitors
• the use of 10 days coarse if systemic antibiotic
plus Pen G limit the spread of nephritogenic
organism.