ADMISSION CONFERENCE

CASE DISCUSSIONRIVERA, JOANNA GRACEASMPH BATCH 2013OBJECTIVESAt the end of this case presentation, we should be able to do the following:Discuss a case of acute post-streptococcal glomerulonephritisUnderstand the natural course of APSGNUnderstand the pathophysiology, diagnosis and management of APSGNGENERAL INFORMATIONJALFemale2 4/12 years oldFilipinoRoman CatholicNovaliches, Quezon CityInformant: MotherReliability: 90%

CHIEF COMPLAINTDifficulty of Breathing(five days duration)4Three weeks PTAHISTORY OF PRESENT ILLNESSErythematous, pruritic pustules on the lower extremities, trunk and some on the faceNo associated fever, cough and coldsNo medications takenNo consult5Two weeks PTAHISTORY OF PRESENT ILLNESSEdemaPeriorbital area and on the lower extremitiesAbdominal distentionNo other associated symptoms

6Five days PTAHISTORY OF PRESENT ILLNESSProductive cough had difficulty of expectoratingSlight difficulty of breathingNo associated colds and fever7Five days PTAHISTORY OF PRESENT ILLNESSSought consult in health centerBronchopneumoniaAmoxicillin 7.5 ml every 8 hoursSalbutamol 4 ml every 8 hours

8One day PTADAY OF ADMISSIONDecrease in the amount of urineWith associated tea-colored urineHISTORY OF PRESENT ILLNESS9Review of SystemsGeneral: (-) changes in weight, (-) sweats, (+) weakness, (-) fatigueSkin: (-) itchiness, (-) color changes, (-) pigmentation, (+) rashes, (-) photosensitivity, changes in hairs and nailsEye: (-) blurring of vision, (-) redness, (-) itchiness, (-) pain, (-) increased lacrimation10Review of SystemsEar: (-) deafness, tinnitus, dischargeNose: (-) epistaxis, discharge, obstruction, postnasal dripMouth and throat: (-) bleeding gums, sores, fissures, tongue abnormalities, dental caries, (-)sore throat, lump sensationPulmonary: (-) hemoptysis11Review of SystemsCardiac: (-) easy fatigability, orthopnea, nocturnal dyspnea, syncope, edemaGI: (-) retching, hematemesis, melena, hematochezia, dysphagia, belching, indigestion, food intolerance, flatulence, (-)abdominal pain, (-) diarrhea, (-) vomiting, constipation, anal lesion

12Review of SystemsGU: (-) urinary frequency, urgency, hesitancy, nocturiaMusculoskeletal: (-) joint stiffness, pain, swelling, cramps, muscle pain, weakness, wastingEndocrine: (-) heat-cold intolerance, polyuria, polydipsia

13Review of SystemsHematopoietic: (-) abnormal bleeding, (-) bruisingNeurologic: (-) headache, seizure, mental status changes, head trauma

14PAST MEDICAL HISTORYDenies previous history of recurrent throat infectionsNo other illnessesNo previous hospitalizations/surgeriesNo known allergies to food and medications15BIRTH AND MATERNAL HISTORYBorn full term via NSD to a 36 year old G6P6 in a lying in clinic attended by midwifeBW: 2.6 kgDenies any perinatal or neonatal complications

IMMUNIZATION HISTORYEPIBCG (1 dose)DPT/OPV (3 doses)Hep B (3 doses)Measles (1 dose)

NUTRITIONAL HISTORY24 hour : Breakfast: 3 pandesals with half glass of chocolate milk (sometimes with egg)Lunch: 1 cup rice with soup and vegetables (squash)Dinner: 1 cup rice, soup and chickenLoves eating chocolates, candies and junk foodsCan finish 2 glasses of softdrinks/day18NUTRITIONAL HISTORYBreastfed until 2 monthsFormula fed with Nestogen (3 ounces/bottle)Weaning age: 6 months (Cerelac); 9 months (rice)19Developmental HistoryGROSS MOTOR8 months: sits with support10 months: stands with support1o months: walks with support15 months: walks well alone2 years: runs well, can climb up and down stairs2: jumpsFINE MOTOR9 months: holds bottle1 year and 3 months: can drink from cup2 years old: can imitate a circle

LANGUAGE9 months: can speak mama and papa1 and year: can indicate needs; can speak three-word sentences2 years old: can point to parts of the body and can follow directionsLANGUAGE2 years:can remove garment; toilet trained; uses spoon

FAMILY HISTORYMaternalAsthma (grandmother)TB (uncle)

PaternalHypertension (Father and grandfather)

21GENOGRAM37381512106321 4/12Jeepney driverHousewifePERSONAL-SOCIAL HISTORYLives in a one-storey two-bedroom bungalow house. Two older sisters are living in the province with their grandmotherWater source: Nawasa (most often, not boiled)Garbage collected once a weekHouse is near factory of buttons and a cellular site.PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONGENERAL APPEARANCEAlert, irritable, weak-looking, in respiratory distressVITAL SIGNSBP: 100/70 RR: 48 O2 Sat (room air): 89%HR: 150Temp: 36.7ANTHROPOMETRICS:Height: 82 cm (-2) Weight: 11 kg (-2 to 0)BMI: 16.4 (0-1) Weight for Height: 0-1HC: 46 cm (-1) CC: 53 cmAC: 51 cm

25PHYSICAL EXAMINATIONSKINdry but warm skin, good skin color and turgor,multiple macular and patches (1cm in greatest diameter), with some crusting on both lower extremities26PHYSICAL EXAMINATIONHEENTno lesions or matting of the eyelids, no eye discharge, periorbital swelling, anicteric sclerae, pale palpebral conjunctiva, facial swellingNo tragal tenderness, no ear discharge, intact TM(+) alar flaring, nasal septum midline, with minimal nasal dischargedry lips, moist tongue, no buccal mucosal lesions, no TPCno masses in the neck, (-) CLAD, flat neck veins27PHYSICAL EXAMINATIONCHEST(+) Intercostal and subcostal retractions, symmetric chest expansion, crackles and wheezes on both lung fieldsHEARTadynamic precordium, no thrills, heaves or lifts, PMI at 5th ICS, MCL, tachycardic, regular rhythm, good S1 and S2 sounds, (-) murmursABDOMENglobular, slightly distended, normoactive bowel sounds, no organomegaly, no tenderness28PHYSICAL EXAMINATIONEXTREMITIESfull and equal pulses, Grade 2 bipedal edema, no atrophy/hypertrophy, no deformitiesGENITALIAGrossly female, no genital discharge, no lesions, no erythemaNEUROLOGIC EXAMINATIONIntact cranial nerves, no sensory and motor deficits, normoreflexive, (-) Babinski, (-) clonus29SALIENT FEATURESSUBJECTIVEOBJECTIVE2/Fhistory of skin infectionDifficulty of breathing with associated cough and fever, unrelieved by medicationsAcute onsetdecreased urine outputEdemaTea-colored urine Cardiorespiratory distressTachycardia, tachypneaAlar flaringRetractionsCrackles and wheezesPeriorbital and facial edema,abdominal distentionGrade 2 bipedal edema

PRIMARY WORKING IMPRESSIONDifferential DiagnosisPCAPIgA Nephropathy (Berger nephropathy)

Management in the ERNPO temporarilyIVF: D5LR 500 cc to run at 65cc/hrO2 supplementation at 2LPM via nasal cannulaDiagnostic TestCBC with APCTherapeutics:Ampicillin 275 mg/IV every 6 hoursSalbutamol nebulizaton every 15 minutes x 3 doses then every 2 hoursInitial Laboratory ResultsCBCHgb86MPV7.30Hct0.26RDW13.14WBC8.6MCV73.34Neutrophils0.66MCH24.04Lymphocytes0.28MCHC32.78Monocytes0.05Basophils0.01Platelets4921st Hospital DayS/O> awake, irritable, still in respiratory distresstachypneic, afebrilefacial and periorbital edema(+) alar flaring, (+) retractions, SCE, (+) crackles and wheezes, both lung fieldsgrade 2 bipedal edemaA> Pneumonia, t/c Acute Post-Streptococcal Glomerulonephritis1st Hospital DayP> Referred to PIDS, Nephro, Cardiology Repeat CBC, Urinalysis, ASO, C3, Blood CS, serum electrolytes, BUN, Crea, TPAGKUB ultrasoundCKMB and 2D echoShift antibiotics to Penicillin G 500,000 U IV every 6 hoursFurosemide 10 mg/IV every 6 hoursFamotidine 5 mg IV every 12 hoursMaintain O2 at 10 LPM every 6 hours

Laboratory ResultsCBCHgb83.6MPV7.20Hct0.25RDW13.90WBC8.2MCV76.70Neutrophils0.78MCH25.70Lymphocytes0.19MCHC33.50Monocytes0.03Platelets375PHYSICALColorYellowRBC269TurbidityHazyWBC10Reaction6.9EC1S. Gravity1.017BacteriaFewMucusOccasionalCast13CHEMICALGlucoseTraceUrobilinogenNormalBilirubinNegativeNitriteNegativeKetoneNegativeBloodLargeProtein 2+LeukocytesNegativeCXR: pulmonary congestion2D Echo: Cardiomyopathy, mitral regurgitation, mild, pericardial effusion posterior (0.55-0.60 cm)ABG: metabolic acidosis

ABGpH7.38pCO227pO2144HCO316ELECTROLYTESNa141K3.7Cl109Ca1.94Creatinine47BUN5.1Total Protein57.2Albumin25.4Globulin31.8A/G Ratio0.82nd Hospital DayS> Still with cough and difficulty breathing, tea- colored urineO> Wt: 10 kg (from 11 kg), AC: 48 cmtachypneic, tachycardicdecrease facial and periorbital edema(-) alar flaring, (+) subcostal retractions, (+) crackles and wheezesslightly distended, NABS, soft abdomendecrease bipedal edema

CBCHgb90.4MPV7.3Hct0.26RDW12.83WBC7.4MCV73.37Neutrophils0.30MCH24.05Lymphocytes0.52MCHC32.78Monocytes0.13Eosinophils0.01Basophils0.04Platelets444ASO: 200 IU/mLUO: 3.5 mL/kg/hrRepeat serum electrolytesNa: 145K: 3.9Cl: 105Ca: 2.07

2nd Hospital DayA> APSGN, pulmonary congestion with associated bronchopneumoniaP> Continue medications Fluid limit to 250 cc/dayStart Low salt dietStart KCL syrup 10 mL TID

3rd Hospital DayS> (+) minimal cough, some episodes of DOBDark-colored urineO> awake, not in respiratory distress normal vital signs Decreased facial and periorbital edema(-) alar flaring, (+) slight subcostal retractions, (+) bibasal crackles AC: 46 cm, non-tender abdomen decreased edema Blood CS: no growth after 24 hours incubationUO: 2.1 mg/kg/hr3rd Hospital DayA> APSGN, pulmonary congestion, resolving BronchopneumoniaP> Same4th Hospital dayS/O> Patient transferred to regular roomAwake, ambulatory, not in respiratory distressStable vital signsNo periorbital or facial edemiaSCE, cracklesAC: 46 cmLabs: C3: 0.02 g/L (low)U/O: 3.2 mg/kg/hrA> Post-infectious glomerulonephritis, resolvingP> Decrease Furosemide to 20 mg/tab tab every 12 hours Still for KUB-UTZ Discontinue fluid limit intake

5th Hospital DayS> occasional cough with colds, lighter colored urineO> awake, ambulatory, not in respiratory distress No facial or periorbital edema (-) alar flaring, SCE, clear breath sounds (-) abdominal distention, (-) edemaA> APSGN, resolving; bronchopneumoniaP> May go homeTake home medications: Co-Amoxiclav 250 mg/62 mg/5mL, 3mL every 8 hours for 10 daysFurosemide 20 m/tablet, tablet once daily for 3 days

DISCUSSIONAcute poststreptococcal glomerulonephritisAcute nephritic syndromeSudden onset of gross hematuriaEdemaHypertensionRenal insufficiencyFollows infection from GAS: pharyngitis (serotype 12) or pyoderma (serotype 49)97%: less-developed countries52Post-infectious glomerulonephritisOther causes:Coagulase-positive and negative staphylococciStrep pneumoniaeGram-negative bacteriaAcute poststreptococcal glomerulonephritisPathology:Symmetrically enlarged kidneysLight microscopy: diffused mesangial cell proliferation, with increase in mesangial matrixImmunofluorescence: lumpy-bumpy deposits of Ig and complement on GBMEM: electron-dense deposits or humps97%: less-developed countries54PathogenesisCirculating Immune complex formation with streptococcal antigens and subsequent glomerular depositionMolecular mimicryM proteinsStreptococcal pyogenic exotoxin (SPE B)Nephritis-associated streptococcal plasmin receptor (NAPlr)Clinical Manifestations1-2 wks: streptococcal pharyngitis3-6 wks: pyodermaHypertensive encephalopathy: blurred vision, severe headaches, altered mental status or seizuresPulmonary edema and heart failure: respiratory distress, orthopnea and cough

Clinical ManifestationsPeripheral edema: salt and water retention95% of cases