Acute

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

History of Present Illness

2 weeks prior to admission
Sore throat x 2 days
Difficulty of swallowing
(-) fever
(-) cough
(+) lesion on both legs
No treatment done

1 week prior to admission

Tea-colored urine, foamy, volume
of approximately cup (100-150
ml)
(-) dysuria, (-) DOB
No consult done

3 days prior to admission

Still with tea-colored urine
Facial swelling and periorbital
edema
More decrease on urine volume

2 days prior to admission

Persistence of hematuria and facial
swelling prompted consult
Urinalysis and UTZ of KUB was
done
Treated as UTI and was given
ciprofloxacin; UTZ unremarkable

1 day prior to admission

Progression of the edema. Noted
swelling of both legs
Prompted admission

Past Medical History

(-) Hypertension
(-) Diabetes
(-) recurrent sore throat
(-) CAD
(-) Thyroid problems
(-) Asthma

Family History
(-) Hypertension
(-) Diabetes
(-) Renal problems

Personal History
(-) Smoker
(-) Alcoholic
(-) Allergies

Review of System

General: (-) weight loss, (-) chills, (-)

malaise

Skin: (-) discoloration, (-) pallor (-)

cyanosis

HEENT: (-) blurring of vision (-) colds

Respiratory: (-) cough, (-)

hemoptysis

CVS: (-) Chest pain (-) palpitations

(-) orthopnea, (-) PND


GUT: (-) urgency, (-) frequency, (-)
discharges

Hematology: (-) easy bruising, (-)

epistaxis

GIT: (-) abdominal pain, (-) vomiting,

(-) diarrhea, (-) melena

Endocrinology: (-) polyphagia (-)

polydipsia (-) polyuria (-) heat
intolerance

Neurologic: (-) loss consciousness,

(-) seizure

Extremities: (-) Intermittent

claudication

Physical Examination

General Survey: Conscious, coherent,

ambulatory, not in CR distress.

Vital signs:
BP = 200/100mmHg (sitting)
CR = 89 BPM RR = 19 T =
36.7C
Weight = 69 Kg Height = 54
BMI =

Skin: (-) macular rash on both lower

legs; (-) pallor
.

HEENT: (+) periorbital edema, Pink

palpebral conjunctiva, anicteric sclera,
enlarged & hyperemic tonsils, (-)
exudates, no palpable masses, no
cervical lymphadenopathies
Chest/Lungs: (-)widening of ICS,
symmetrical chest expansion,equal tactile
fremitus on both sides, vesicular breath
sounds, no rales

CVS: No neck vein distention, adynamic

precordium, apex beat is at 5 th LICS MCL,
normal S1 and S2, no S3 or S4, no
murmurs, no bruit
GIT: abdomen is flabby, umbilicus
inverted normoactive bowel sounds, no
bruit, soft and non-tender, no mass, liver
and spleen not palpable, tympanitic on
percussion, Traubes space not obliterated

Extremities: (+) bipedal edema

grade 2, no digital clubbing,
peripheral pulses equal and
bounding

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

Lipid profile, FBS

CXR PA
ECG 12 leads
UTZ of KUB
ANA, C3
HBsAg
Random urine protein/creatinine
ratio

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

Chest X-Ray Impression

Pneumonia, Bibasal

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

840 mg/mmol 22.60

24.10 U/L
Negative

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.

 90% of cases affect children

between the ages of 2 and 14
years
10% of cases are patients
older than 40
The risk of PSGN is increased in
older patients (greater than 60
years of age) and in children
between 5 and 12 years of age.

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.

The mechanisms for the

immunologic glomerular injury
induced by GAS infection:
Planted antigen
Deposition of immune complexes
Alteration of normal renal
antigen
Antigenic mimicry

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)

Abrupt onset of hemutaria (100%)

Proteinuria (80%)
Edema (90%)
HTN (60-80%)
Mild to moderate renal
insufficiency (25-40%)
Subclinical to clinically overt dx
4-5:1

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

After a pharyngeal infection,

the ASO, anti-DNAse B, antiNAD, and AHase titers are
commonly elevated.
In comparison, only the antiDNAse B and AHase titers are
typically increased after a
skin infection.

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%)