Back Pain...Poststreptococcal glomerulonephritis

8/13/2019 Back Pain...Poststreptococcal glomerulonephritis

1/20

S

Pediatrics MorningReport

Whats with this Back Pain?!?

Judy Vu, MD

Med-Peds PGY4December 13, 2013


2/20

History of Present Illness

S 14 y/o previously healthy white girl p/w bilateral back pain

S Achy in mid back, progressed to lower back, nagging pain

S Rated 5-8/10, duration ~4 days, no real exacerbating or relievingfactors

S Recalls back soreness ~1 week ago after raking a lot of leaves inthe backyard, resolved quickly and now returned

S Decreased appetite and PO intake over the same timeS NBNB emesis through the night4 nights ago

S PCP evaluation the next morning (3 days prior to presentation)

S CXR negative

S Zofran prescribedhelped until morning of presentation


3/20


4/20

Additional History

S Allergies: Decadronagitation and mood changes

S Meds: PRN albuterol, PRN Zofran, PRN ibuprofen x2 for backpain. PRN Midol or ibuprofen for menstrual cramps. Advil + Alevein large amounts 3 months ago after ACL tear.

S PMH: No chronic illnesses, hospitalizations, or UTIs. Menstrualcycles normallast 1 week ago. UTD on immunizations

S PSH: Tonsillectomy & adenoidectomy, thumb surgery

S Fam Hx: No chronic conditions. Maternal aunt with renal stones.

S Soc Hx: Lives with parents and sibs. Sister sick with URI. Attends9thgrade, enjoys school. No EtOH, tobacco, or other illicits.


5/20

Physical Exam

VS: T 37.1, HR 70, RR 14, BP 118/77, Sat 100% on RAGEN: Tired but non-toxic, lying in bed wrapped in blankets,

pleasant, cooperative, NAD

HEENT: NCAT, EOMI, no conjunctival injection, ears wnl, NP

clear, no OP erythema or lesions, MMM/pink

Neck: supple with full ROM, shotty LAD

CV: RRR, nl s1 and s2, no murmur/gallop, normal pulses, CRT mid-back. Nodistinct CVA tenderness.SKIN: No rashes, mottling, jaundice

NEURO: A&O x4, face symmetric, grossly normal strength/tone,

normal reflexes.


6/20

One Liner Synopsis

14 year-old previously healthy girl with 4 days of progressive

lumbar back pain, anorexia/decreased appetite, intermittent

nausea, NBNB emesis, intermittent fevers


7/20

Differential Diagnosis

S Renal

S Acute renal failure

S Dehydration

S

NSAID useS GN: RPGN, Crescentic

S Tubulointerstitial: ATN, AIN

S Post-obstructive

S Chronic kidney disease

S Infectious

S UTI

S Pyelonephritis

S Paraspinal abscess

S Osteomyelitis

S POTS/TB

S MSK

S Muscle sprain/spasm

S Rhabdomyolysis

S Bruised boneS Vertebral fracture

S Heme/Onc

S Osteosarcoma

S Myosarcoma

S Multiple myeloma

S Rheumatology/Immunology

S Lupus

S Ankylosing spondylitis

S Juvenile Idiopathic Arthritis


8/20

Initial Evaluation

S Received 1 L NS

S LFTs wnl, lipase 181

SInflammatory Markers: CRP 4.1 and ESR 47

S UA: SG >1.030, pH 5, cloudy, large Hgb, neg nitrite,small LE, trace ketones.Micro: >30 WBC, >30 RBC, >30 epi, 3+ bacteria, >30

hyaline casts, 5 WBC casts

8.8

12

35 209

13B, 47N, 32L, 8M

146 102

794.6 19 8.14

7.7

84

1.6

3.1


9/20

S Renal Ultrasound:

SRight length 11.3 cm

S Left length 11.2 cm

S Normal 8.8-11.9 cm for agerange

S No obstructive uropathy

S Subtle parenchymalechogenicity in both kidneys

S Micro: + beta-hemolytic GAS

S ASO titer: 219, Dnase B: 286

S C3/C4 levels: 11 / 13

S Anti-glomerular basementmembrane Ab: negative

S MPO/PR3 Antibody: 1 / 0

S ANA: None

S ds DNA: negative

S ANCA:


10/20

Renal Biopsy

S Exudative glomerulonephritis

most consistent with post-

infectious glomerulonephritis

S IgG and C3 staining on IF

S Subepithelial humps on EM

S EM: Subepithelial humps

easily identified, rare

mesangial deposit.

Segmental effacement of

podocyte foot processes. No

crescents.


11/20

Patients Clinical Course

S Patient continued to have symptomatic uremia,hyperkalemia, hyperphosphatemia

SIntermittent hemodialysis started on hospital day #3 x 1week

S BUN 44, Cr 1.63 after 11 days of hospitalization

S Fluid restriction 2.5 L, renal diet (LOW Na, K, Phos)

S Pulse Solu-Medrol PO prednisone

S Hypertensiveamlodipine started at time of discharge

S PRN Lasix for edema or weight gain >2 pounds

S NO NSAIDs!!!


12/20

Complication of - hemolytic

GAS

Nonsuppurative

S PANDAS

S Poststreptococcalglomerulonephritis

S Poststreptococcal reactive

arthritis

S Rheumatic fever

S Sydenhams chorea & other

autoimmune movement

disorders

Suppurative

S AOM, PNA, sinusitis

S Cervical lymphadenitis

S Peritonsillar or retropharyngeal

abscess

S Bacteremia, toxic shock

S Endocarditis

S Fasciitis/myositis

S Meningitis


13/20

Complication of - hemolytic

GAS

S Complication arise predominantly from pharyngitis and

scarlet fever

S Abx reduce severity of acute sx & shorten illness by 1 day

S >90% of treated & untreated pts with acute pharyngitis are

symptom-free by day #7 of illness

S Primary reason for treating uncomplicated strep

pharyngitis?

S Reduce incidence of subsequent rheumatic fever

S Reduce recurrence rate of infection

S Unclear if abx tx reduces risk of APSGN


14/20

Acute Poststreptococcal GN

(APSGN)

S Leading cause of acute nephritic syndrome

S SporadicS Most frequent in ages 2-6

S Recent hx of pharyngitisin winter months

S Rash+ poor personal hygiene in warmer climate

S Occurs 10 days after pharyngitis OR 2 weeks after skininfxn

S Nephritogenic strain of GAS

S Immunity is type-specific & long-lasting! Repeatinfections


15/20


16/20

S Dx based on clinical hxand serologies!S No need for biopsyespecially in children with typical hx

S Urinalysis and RFP

S RBC casts, proteinuria, WBCmay be misdiagnosed as

UTI!!!S Abnormalities may persist up to 6-12 months

S Mild hypoalbuminemia, if any

S Signs of inflammation

S CBCS Leukocytosis with neutrophilia

S Mild normochromic normocytic anemia (dilutional)

S ESR & CRP

S Elevated early

S Effective for monitoring diseaseif either returns to normal afterstopping treatment, the attack is usually over

Diagnosis: APSGN


17/20

Diagnosis: APSGN

S Evidence of preceding streptococcal infection based on

serologies

S Antistreptolysin O titer (ASO)

S ASO peaks at ~4-5 wks, first noted during 2ndor 3rdwk of acute

episode

S Peak titer at time of onset TRUE infxn rather than transient carrier!

S Antideoxyribonuclease B (DNase B)more specific, $$

S Throat cultures often negative by the time APSGN appears

S Complement levelsS VERY LOW C3 and minimal decrease in C4

S LOW C3 and LOW C4 Lupus

S Normal complementIgA nephropathy

S

NO NEED to check CH50a historical thingS Timely measurement!! Typically C3 normalizes in 6-8 weeks!!!


18/20

Course: APSGN

S Prognosis is GOOD!!!

S

>95% of pts recover spontaneously. Self-limitedS Return to baseline renal function within 3-4 weeks w/o

long-term sequelae

S Best indicator of resolved dz: C3 back to normal

S Biopsy indicated if

S Delayed resolution

S Severe renal failure at onset

S Progressive renal failure

S Systemic featurerash, arthralgias, HSM, persistent fevers


19/20

Treatment: APSGN

S Can be managed in primary care setting

S Symptomaticdiuretic & anti-hypertensive if necessary

S Fluid restriction if edemaS Renal diet depending on clinical scenario

S Remember to check BPs and RFP

S HTN & azotemia usually subside in 1-2 wks

S Refer immediately to pediatric nephrologist

S Severe HTN, >99%ile

S Renal insufficiency.


20/20

References

S Hahn RG et al. Evaluation of Poststreptococcal Illness. AAFP2005;71:1949-54.

S Simckes AM, Spitzer A. Poststreptococcal AcuteGlomerulonephritis. Pediatrics in Review 1995;16;278

S Welch TR. An Approach to the Child with AcuteGlomerulonephritis. International Journal of Pediatrics.2012

S http://www.nlm.nih.gov/medlineplus

S http://www.niddk.nih.gov/

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Back Pain...Poststreptococcal glomerulonephritis