St. Paul University PhilippinesSCHOOL OF MEDICINETuguegarao City, 3500

BRIOSOS, HAROLD B.UBINA, REI KRISTOFFER C.

Informant: Mother and patient (87 % reliability)

General Data: This is a case of patient JT, a 15 year old, female, Filipino, Roman Catholic, born on February 15, 2000, currently residing at Penablanca, Cagayan, was admitted for the first time at Cagayan Valley Medical Center on March 31, 2015.

Chief Complaint: Lower extremity and periorbital edema

History of Present IllnessThe patient was apparently well until 4 months prior to admission, when the patient manifested sore throat infection accompanied by intermittent low grade fever (undocumented), cough and colds, without any other associated symptoms. There were no consult or any interventions and medications done.

2 months PTA, patient JT manifested sudden onset of mild extremity and periorbital edema but with no other associated symptoms such as easy fatigability, fever, or changes in urination. This prompted her mother to seek consult at Penablanca Health Center and thus the patient was advised to take Clarithromycin and Sambong twice a day. These medications provided the patient temporary relief. 10 days PTA, the patient again manifested sore throat infection and intermittent low grade fever (undocumented) as well as cough and colds. There were no consult done however, the patient self-medicated with Paracetamol 500 mg 4x a day which provided her relief of her fever. 5 days PTA, the patient again manifested signs of sore throat and low grade fever (undocumented). There were no consult done however, the patient self-medicated with Paracetamol 500 mg 4x a day which provided her relief of her fever.

1 day PTA, the patient manifested another episode of sudden onset lower extremity and periorbital edema that prompted her mother to seek consult at Cagayan Valley Medical Center, hence subsequent admission.

PAST MEDICAL HISTORY:Patient JT had no history of allergies to any food or medication. The patient also had no histories of surgeries and any other medical illnesses.

PRENATAL HISTORY:Patient JTs mother is a non smoker and non alcohol beverage drinker. She had her prenatal checkups every month starting at 3 months of her pregnancy at their Local Health Center. On her 3rd month of pregnancy, she started to take multivitamins and ferrous sulfate until giving birth. She denied any maternal illnesses during the course of pregnancy. Also, the mother had no history of falls/accidents or exposure to radiation and teratogenic drugs. She did not receive any tetatus toxoid vaccine. Also, there was no ultrasound done.

BIRTH HISTORY:The patient was born to a 34 y/o G6P6 (6-0-0-6) mother, cephalic, full term, delivered via normal spontaneous delivery at their house, and was assisted by her husband. The umbilical cord was cut with a bamboo and tied with a thread. Vitamin K was not given. The patients birth weight was unrecalled by the mother. There was no difficulty of labor, morbidity and complications noted. Also, there was no newborn screening done to the patient.

NEONATAL HISTORY:Patient JT had good suck and immediately cried at birth. There were no signs of respiratory distress, jaundice, convulsion or sepsis noted.

FEEDING HISTORY:Patient JT was purely breastfed up to 5 months of age, with good appetite (breastfeeding every 3 hours). Complementary feeding started at 5 months with rice porridge which was prepared with unboiled water. Table food was introduced at 8th month.Her current diet includes meat and vegetables

GROWTH AND DEVELOPMENT:A. Growth: Mother ascertains that the patient was growing normally when she was younger.

MilestoneAge AttainedDevelopment interpretation

Holds bottle6 monthsAppropriate for age

Sits without support8 monthsAppropriate for age

Says mama or papa9 monthsAppropriate for age

Walks alone14 monthsAppropriate for age

Feed self16 monthsAppropriate for age

Enters elementary6 y/o

IMMUNIZATION HISTORY:Complete Primary Vaccines

FAMILY HISTORY:Her brother had the same illness when he was the same age. No other heredofamilial diseases such as HPN, cancer, TB, and asthma were noted.

PERSONAL AND SOCIAL HISTORY:Patient JT is the 5th child among the 6 children of a 49 year-old vegetable vendor and a 50 year old farmer. They live in a 1-storey Bungalow house and their source of water is directly from the pump well and therefore, not boiled. They have no pets.

REVIEW OF SYSTEMS:Integumentary system:(-) pruritus , (-) bruises or neurocutaneous lesionsNervous system: (-) loss of consciousness, (-) seizureCardiorespiratory system: (-) cough, (-) colds (-) dyspnea, (-) hemoptysisGastrointestinal system: (-) abdominal pain (-) diarrhea, (-) constipation, (-) melena, (-) anorexia, (-) vomitingGenitourinary system :(-) hematuria, (-) oliguriaMusculoskeletal system: (-) myalgia, arthralgiaHematologic system: (-) bleeding tendenciesEndocrine- metabolic system: (-) weight loss, (-) fever (-) easy fatigability, (-) sweating, (-) chills

PHYSICAL EXAMINATIONGeneral Description:The patient is awake, alert and oriented to time, person, place and not in cardiorespiratory distress.Vital signs:Temp: 36.2 oC (Afebrile)HR: 100 bpm RR: 18 cpm BP: 140/90 (Hypertensive)Anthropometric measurements

Weight 38.5 Kg. (5th percentile)

Height 160 cm. (25th percentile)

BMI15.3 kg (Underweight)

Skin: Warm to touch; Good turgor, No jaundice, no palmar pallor, no lesions and rashes; Head: Normocephalic. Hair is evenly distributed and scalp is free from lesions and masses.Eyes: Anicteric sclera, pale palpebral conjunctiva. No asymmetry. No periorbital edema. No discharges. No epicanthic fold. Ears: Clear external auditory canals no signs of inflammation noted. Pinnae is normal in shape, Tympanic membrane is shiny and pearly grey.Nose: No nasal discharges, no obstruction, no nasal flaring.

Mouth: No cleft lips or palate and other deformities; uvula and tongue in midline; tonsils are inflamed (Grade 2+: Tonsils occupy less than 50 percent of the lateral dimension of the oropharynx).Neck: No lumps or masses, trachea midline. With cervical lymphadenopathy. No Jugular vein distentionThorax and Lungs: Symmetrical chest expansion; No intercostal and suprasternal retraction. (-) wheezes (-) crackles. Heart: Adynamic precordium. No palpable thrill. Normal heart rate and rhythm. No murmurs. PMI at 5th ICS left MCL

Abdomen: Flat. No distention or swelling; Normoactive bowel sounds with 6 BS/minute; Tympanitic on percussion; non-tender, no masses, no hepatomegaly, spleen not palpable, (-) pain in the flank area.

Genito-urinary: Grossly female, Stage 4 on Tanner staging. Patent Anus.

Extremities: No gross deformity; no clubbing, no masses. With Bipedal pitting edema (Grade 3+Generalized bilateral pitting edema, which includes both legs, feet and face (periorbital). Pale nail beds. Full and equal pulses. CRT 2 sec.

Neurologic Exam

MSE: Patient is awake conscious and coherentCerebellar: No NystagmusCN: I Intact able to smell II Pupil equal 2-3mm, Reactive to light and accommodation III, IV, VI able to follow objects (intact EOM) V (+) corneal reflex VII symmetrical face VIII respond to voice IX, X (+) gag reflex XI can move head from side to side and shrug shoulders XII tongue at midline

Motor:RU - 5/5LU - 5/5

RL - 5/5LL - 5/5

Sensory: Pain sensation is intact 100% in all extremities

DTR:Brachioradialis Biceps TricepsPatellarplantar

Left2+2+2+2+2+

Right 2+2+2+2+2+

Meningeal sign: Negative Nuchal rigidity, Brudzinski, and Kernigs

CLINICAL IMPRESSION: Acute Post-Streptococcal GlomerulonephritisSalient Features:History of sore throat accompanied by cough and coldsLower extremity and periorbital edemaHypertensionFever

Differential Diagnoses:1. IgA NephropathyIgA Nephropathy or Bergers Disease is common in older children and has a higher predilection to male than female 2:1. It has an acute onset of fever and hematuria. 30 - 50% of cases can have Hypertension and Edema of the hands and feet. Our patient Manifested acute onset of fever but with absent hematuria and was hypertensive upon admission. Edema was primarily manifested in the face periorbital and lower extremities.RULE INRULE OUT

Fever(-)Recurrent episodes of gross hematuria, followed by persistent microscopic hematuria

Hypertension(-)Pain in the flank

2. Tubulointerstitial NephritisKidney disease that involve structures in the kidney outside the glomerulus. Most common form is hypersensitivity reaction to Medications but can also be caused by infections. Typically it begins abruptly. Our patient manifested with fever and hypertension and he also presented with hematuria.RULE INRULE OUT

Fever(-) Recent NSAIDS or Antibiotic use

Hypertension(-) Rash

3. Nephrotic Syndrome Minimal-change disease (MCD), also known as lipoid nephrosis or nil disease, is the most common single form of nephrotic syndrome in children. Manifestation present in our patient was presence of Facial Edema and Hypertension. Although not manifested by our patient weight gain and Foamy appearance of urine is also common in MCD patient.RULE INRULE OUT

Facial Edema(-) Foamy appearance of urine

Hypertension(-) history of NSAID use.

(-) Weight gain and Ascites

Case Discussion

Acute Glomerulonephritis

Glomerular lesions in acute GN are the result of glomerular deposition or in situ formation of immune complexes. Acute poststreptococcal glomerulonephritis (APSGN) results from an antecedent infection of the skin (impetigo) or throat (pharyngitis) caused by nephritogenic strains of group A beta-hemolytic streptococci. PSGN occurs most frequently in children 2 to 12 years of age and is more common in boys. Family studies have suggested genetic predisposition for APSGN. Manifestations of PSGN are typical of acute GN listed previously and develop 5 to 21 days (average 10 days) after streptococcal pharyngitis infections and 4 to 6 weeks after impetigo. PATHOPHYSIOLOGY OF APSGN

Group A hemolytic streptococcus antigens (M-type 12) + antibody

Antigen-antibody complex + IgG

Activates the complement system c3 which deposits on the GBM serum c3 concChemotactic plasma activated complement (c5a)Platelet-derived inflammatory mediators Cytokines and cellular immunity factorsPMN leukocytes Inflammatory response GBM destruction hematuria, dysuria Edema of the capillary walls permeability of glomerular capillary wallsCapillary lumen narrowed proteinuriaImpedes glomerular perfusion urinary protein loss Oliguria hypoalbuminemia activation of the RAAS plasma oncotic pressure and transudation of fluid from IV compartment to interstitial spacestimulates the release of ADH whichenhance the absorption of water in the collecting duct

hypertensionAnasarca hypervolemia nausea, headache, vomiting hemodilution anemia

Clinical Manifestations

Hematuria (gross or microscopic) Other cardinal features of glomerular injury Proteinuria Hypertension Edema Oliguria Renal insufficiency

WORKUPUrine analysis: Dysmorphic or crenated red blood cells and red blood cell casts. Proteinuria, usually moderate, reaches the nephrotic range in 5 to 10% of patients with APSGN. Leukocyte, hyaline, and granular casts are also frequently seen. Transient elevation of blood urea nitrogen and serum creatinine.

Antibody Titers Recent streptococcal infection. Increased titers of antibodies.

Serum levels of IgG and IgM are elevated in 90% of patients.

MANAGEMENTSupportive measures1. Bed rest and limitation of physical activities are measures in most glomerulopathies including PSAGN.1. Dietary Na restriction is acceptable to most children, especially those with mild affliction. 1. Control of dietary protein and potassium.1. Fluids are limited to insensible water loss replacements (usually 20 ml/kg/day under baseline conditions) plus volume for volume replacement of urine output in the preceding 24 hours, minus a planned weight loss. 1. All fluids should be given orally when tolerated, preferably as nonelectrolyte preparations initially. If that is not possible, electrolyte free intravenous fluids are used.

Drug Therapy4. Loop diuretics particulary furosemide or ethacrymic acid - promote diuresis and to treat mild to moderate hypertension. 4. Diazoxide - hypotensive agent; Hydralazine 4. Reserpine used to be a drug of choice; however, its onset of action is so unpredictable, it produces extra-pyramidal side effects and causes discomforting nasal stuffiness. 4. Sublingual and oral calcium channel blockers (nifedipine) in severe and mild to moderate hypertension, respectively. 4. ACE Inhibitors such as captopril, are currently recommended as additional agents for mild-to-moderate hypertension.4. Penicillin - To eradicate residual foci of streptococcal infection, given either orally or parenterally, the former route being preferred if tolerated. In case of penicillin hypersensitivity, erythromycin is substituted.

PROGNOSIS

The course and prognosis for acute poststreptococcal glomerulonephritis (APSGN) is well known and almost always favorable in children, but this is not so with nonstreptococcal forms of the condition.