1. Presented by Int. 吳志勳 Instructed by VS. 邱元佑
Intern Seminar
Presented by Int. 吳志勳
Instructed by VS. 邱元佑

2. Basic Information Name : 歐x賢 9 y /o boy Date of admission: 93/01/18
No underlying disease
Normal growth and development
C.C: Weight gain around 5 kg over this
half a month (49.5→54.5 kg)

3. Present Illness Sore throat about 1+ week ago
Increasing abdominal girth
SOB easily was noted while exercise
Headache (+), two times
URI symptoms (+), no fever
No dysuria/ grossly hematuria/ frequency
forehead and bil. eyelid swelling on 1/18
→ to our ER

4. Physical Examination ER: T/P/R:36.6/90/18, BP:162/128 puffy eyelid (+)
Throat ~ non-injected
Bil. clear breathing sound
Abd.~ Soft, distention
Extremity ~ no pitting edema
Hydrocele (-)

5. Lab (1/18) CBC/DC WBC Hb Plt Band Seg Lymph 9.9 11.5 261 9 53 22
Biochemistry
CRP BUN Cr GOT GPT Na K Cl
CA P

6. Lab ~ UA (1/18) SG 1.025 PH 6.5 LEU 15 /UL NIT NEGATIVE
PRO >=300 MG/DL GLU NEGATIVE MG/D
KET NEGATIVE MG/D UBG MG/DL
BIL NEGATIVE MG/D ERY /UL
WBC /HPF RBC >100 /HPF
Epith /HPF Cast /HPF
Crystal - /HPF Bacteria -
Dysmorphic RBC 75%

7. Tentative diagnosis
Nephrotic syndrome
R/O nephritis

8. Admission and Plan Albumin supplement and diuretic use
Check Chol/TG, IgG/transferring
Throat swab ~ Group A Strep. infection
24hr urine ~ check CCr and protein loss
Arrange Renal echo

9. Lab after admission on 1/18
Alb T-pro
→ hold albumin
→ keep lasix using

10. Lab (1/19) IgA 148 mg/dl C3 L 21.0 mg/dl C4 N 19.3 mg/dl ASLO H 500 IU
IgG mg/dl

11. Final Diagnosis
Poststreptococcal glomerulonephritis

12. Clinical Course Lasix 1 A’ qd → 1 A’ q12h → 2 A’ q12h
for fluid over load and HTN
Renitec 20mg 1# qd for HTN
Adalat 1# prn for HTN
Aq-penicillin 5M u q6h
Low salt diet

13. Clinical Course 1/18 1/19 1/20 1/21 BW 54.4 52.6 51.9 50.3 (49.5)
1/ / / /21
BW (49.5) AC U
SBP
DBP

14. Lab (24 hr urine) 3542 mL/24h under lasix 1 A’ q12h
CREA L 26.6 mg/dL
TP mg/dL
Ccr ml/min per 1.73 m2

15. WBC (1/18) 10 (1/19)
CRP (1/18) <7 (1/19)
Throat swab : Normal flora isolated
U/C : No bacteria was isolated
B/C : No bacteria was isolated
Renal Echo: normal

16. MBD Medication Renitec 20mg 1# qd Lasix 1# bid
Aldalat 10mg q6h prn if BP > 140/90
Amoxil 3# po tid

17. OPD (93.1.28) BW 49.5 kg (baseline) Edema (-)
Urine output ok s/p lasix using
Renitec 20mg 1# qd * 2wks
Lasix 1# bid * 1wk

18. Poststreptococcal glomerulonephritis
Discussion
Poststreptococcal glomerulonephritis

19. Etiology
occurs 7 to 14 days after infection of group A beta haemolytic streptococcus
Throat and skin infection
Latent period 10+ days

20. Nephritogenic strains
Group A
β- hemolytic
Respiratory tract - M1, 2, 4, 12, 18, 25
Skin – M49, 55, 57, 60
Group C
Streptococci
Streptococcus zooepidermicus

21. Epidemiology accounts for 90% of acute GN in chikdren
mostly in the under fives, but may occur in early adolescence and in adults
Male : female = 2:1

22. Clinical Features Sudden, painless, gross hematuria
Tea or cola-colored urine
Edema, puffy eye, hydrocele
HTN
Proteinuria, oligouria
Heart failure, ARF, encephalopathy

23. Lab Finding Hematuria, dysmorphic RBC, cast Hypertension Proteinuria
BUN, Cr ↑
C3↑, C4 normal
Strp. inf. ~ antistreptozyme、ASLO…

24. Pathophysiology Complement, alternative pathway↑
Glomerular proliferative and inflammatory response
Antigen-antibody complexes in basement membrane
Induce complement activation
GFR、filtration↓→ Na+ reabsortion↑

25. Pathology Proliferative GN Kidney symmetrically enlarged
The basement membrane is swollen
mesangial cell proliferation
PMN infiltration
C3 and IgG deposition
Subepi. Electron dense deposits (Humps)

30. Diagnosis History ~ sore throat, skin inf. PE ~ HTN, fluid overload
Urine sample ~ U/A, 24hr urine
Biochemistry ~ albumin, protein, cholesterol
complement ~ C3, C4
Antistrep. Ab ~ ASLO, streptomzyme
collagen vascular disease screen
throat swab and skin culture

31. Renal Biopsy Unresolved ARF Nephrotic syndrome C3 normal
Absence evidence of strep. Inf.

32. Treatment Essentially supportive Diuresis Antihypertensive agent
Fluid and sodium restriction
Treatment for ARF
Antibiotics within 36~72 hr of inf.

33. Treatment, still controversial
Steroid
Bed rest
→ severe, ie. encephalopathy
→ outcome of proteinuria
Antibioyics
→ 36~72 hr of nephritogenic strep. Inf
→ family, 20% asymptomatic PSGN

34. Prognosis 92~98% recover completely GFR 10~14 days
Gross hematuria ~3 wks
BUN/Cr ~4 wks
C ~8 wks
Proteinuria ~6 months
Microscopic Hematuria months to years

35. Poor Prognosis Factors
Old age
Renal insufficiency at the onset
degree of proeinuria

37. Nephrotic Proteinuria in PSGN
Insidious edema
Even microhematuria only
HTN and azotemia

39. Nephrotic Proteinuria in PSGN
Glomerulosclerosis and CRF
→ degree of proeinuria correlated with
histological grade of renal biosy
→ crescents in more then 1/3 of
glomeruli