MORNING REPORT

Caitlin Kaeppler, MD PGY-3

HPI
14yo previously healthy male who was diagnosed with otitis media 3
weeks prior to admission, treated with azithromycin.
He seemed to recover after the treatment until 1 week prior to
admission when he woke up with a swollen face. His mom thought
this was allergies, so she gave him Benadryl along with his once daily
Claritin.
His swelling decreased throughout the day but was back the next
morning. This continued for the next few days.
Two days prior to admission, he did a lot of walking at the zoo and
developed swelling in his legs afterward. This worsened over a
couple days. His mother took him to the family physician where he
was found to have gained 19 lbs and had systolic BP in
150s. He was also short of breath.
He was referred to the Emergency Department at an outside hospital
where he was requiring oxygen and was admitted.
On the third day of hospitalization, he started to complain of
peripheral vision changes. Therefore, he was transferred to PCH
PICU.
PMH
History of multiple ear infections

No meds

Allergic to Augmentin
FH
None significant
SH
Lives with parents and two siblings
Physical Exam
VS: T: 37.1. HR: 108. RR: 20. BP: 132 /80 . SaO2 96 % on Nasal Cannula at 0.5 LPM.
Weight: 58.00kg (41%ile), Height 169 cm (59%ile)

GENERAL: laying in bed, mildly irritated with providers but no distress, interacting normally for age and
situation
HEAD: normocephalic, atraumatic.
EYES: both pupils briskly reactive to light, anisicoria L pupil about 1.5mm > R pupil
NOSE: no discharge or obstruction.
OROPHARYNX: moist mucus membranes, no mucosal lesions
NECK: supple without lymphadenopathy or tenderness to palpation.
CARDIOVASCULAR: normal rate, rhythm, and S1/S2, without murmur or gallop. Pulses appropriate.
Capillary refill time <2 seconds.
LUNGS: clear to auscultation bilaterally, diminished air flow in the bases with some scattered
crackles, no retractions.
ABDOMEN: soft, non-tender, non-distended with active bowel sounds and no masses or
hepatosplenomegaly. No fluid wave or ascites appreciated
EXTREMITIES: all extremities warm and well perfused. Edema in lower extremities bilaterally, non
pitting, no nail pits or nail bed abnormalities, no swelling in hands
BACK: small scar on left flank
GENITOURINARY: (Attending exam with charge nurse Brian Vincent) normal uncircumcised TIV male
genitalia, testes descended bilaterally with normal cremasteric reflex, no scrotal swelling or rash, normal
sphincter tone
NEUROLOGIC: awake and alert, GCS 15, grossly normal strength and tone, patellar tendon reflexes
normal.
SKIN: no rashes or petechiae on skin

Patient summary:
14yo previously healthy male with facial and extremity
edema, hypertension, shortness of breath, and vision
changes.
Differential diagnosis
Renal
Poststreptococcal GN
MPGN
IgA nephropathy
SLE
HSP
Alport syndrome
Hepatitis B associated GN
Endocarditis associated GN
Post-infectious GN
HUS
Renovascular disease
Nephrotic syndrome
Neuro
Intracranial hemorrhage
Intracranial mass
PRES
HACE
Respiratory
Pneumonia
Pulmonary edema
HAPE
Cardiac
Heart failure
Primary hypertension
Coarctation of the aorta
ID
Pneumonia
Meningitis
Other
Pheochromocytoma
Ingestion
Conversion disorder


Imaging
CXR: Bilateral pleural effusions and pulmonary edema

Head CT: Multiple intracranial hemorrhages


Brain MRI: 3 cm area of abnormal signal and hemorrhage
involving the occipital lobe and a 2.2 cm area of abnormal
signal with punctate hemorrhage involving the right
parietal lobe.

Labs
Prot/Cr 0.4
Lactate 1.8
CBC: WBC 5.7, Hgb 12.8, Hct 38.8, Plt 321 (N 55% L 31.3% M 9.1%
E 3.8%)
CRP 0.1
CMP: Na 141, K 5.1, Cl 112, C02 24, Gluc 69, BUN 17, Cr 0.87 Ca
8.8, Prot 6.6, Alb 3.3, Total Bili 0.5, ALP 166, ALT 47, AST 29
TSH 3.14
Urine Macro: Hgb large, Prot 2+
ESR 22
PT 13.9/INR 1.1
C3 25L, C4 18

RFP: Na 140, K 4.7, Cl 111, C02 21, Gluc 137, BUN 17, Cr 1.02, Alb
2.8, Ca 8.2, Phos 5.2

Further labs
ASO 540
Anti-DNAse B 2120
ANCA negative


4 days after admission: Cr 0.88

Poststreptococcal Glomerulonephritis
Most common cause of acute nephritis in children
Most commonly in ages 5-12
Specific nephritogenic strains of group A beta-hemolytic
streptococcus
Spectrum of asymptomatic, microscopic hematuria to full-
blown acute nephritic syndrome (red to brown urine,
proteinuria, edema, hypertension, and acute kidney
injury)
Poststreptococcal
GN
Pathophysiology:
Glomerular immune complex
disease triggers complement
activation and inflammation
Deposition of streptococcal
antigens in the glomerulus and
subsequent immune complex
formation

Usually developed
Between 1-3 weeks following GAS
pharyngitis
Between 3-6 weeks following GAS
skin infection

Presenting symptoms:

Edema (67%)
Gross hematuria (30-50%)
Hypertension (50-90%)
caused be salt and fluid
retention

Other causes of GN
Membranoproliferative GN
May be indistinguishable from post-infectious GN
Hematuria, hypertension, proteinuria, and hypocomplementemia
Persistent urinary abnormalities and hypocomplementemia beyond
4-6 weeks
IgA nephropathy
Shorter time period between antecedent illness and hematuria
(less than 5 days)
HSP
Other clinical findings (purpura, abdominal pain)
No decrease in complement
SLE
Both C3 and C4 are low (only C3 is low in PSGN)
Work-up
Urinalysis
Hematuria, with or without red cell casts
Varying degrees of proteinuria
Pyuria
Blood
C3 is significant depressed in first 2 weeks of disease (in contrast to
lupus nephritis)
Anti-DNAse B and ASO elevation
Culture
Recent positive throat or skin culture
Renal biopsy
If C3 remains low after 6 weeks, suggestive of MPGN
Recurrent episodes of hematuria suggesting IgA nephropathy
Progressive increase in creatinine
Treatment
Supportive therapy
Treatment of volume overload with anti-hypertensives and loop
diuretics
Sodium and water restriction
Dialysis (rare)
Antibiotics if persistent streptococcal infection
Time course
Diuresis usually begins within 1 week
Serum creatinine returns to baseline within 3-4 weeks
Hematuria resolves in 3-6 months
Proteinuria lingers (15% at 3 years, 2% at 7-10 years)
Prognosis
>90% have normal or only mildly decreased kidney
function 5-18 years after presentation
Can go on to develop hypertension or renal insufficiency
in adulthood
Complications
Encephalopathy (PRES)
Pulmonary edema
Intracranial hemorrhage (very few reports in the literature)

References
Up To Date
Chiu CY et al. Poststreptococcal glomerulonephritis with
pulmonary edema presenting as respiratory distress.
Pediatr Nephrol. 2004 Nov;19(11):1237-40.
Zaki SA and Shanbag P. Unusual presentation of
poststreptococcal glomerulonephritis as posterior
reversible encephalopathy syndrome. J Pediatr Neurosci.
2014 Jan;9(1):42-4.