St.

Paul University Philippines

SCHOOL OF MEDICINE
Tuguegarao 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 Illness
The 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 selfmedicated 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 8 th
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.

Milestone

Age Attained

Holds bottle
Sits without support
Says mama or papa
Walks alone
Feed self
Enters elementary

6 months
8 months
9 months
14 months
16 months
6 y/o

Development
interpretation
Appropriate for age
Appropriate for age
Appropriate for age
Appropriate for age
Appropriate for age

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 lesions

Nervous system: (-) loss of consciousness, (-) seizure
Cardiorespiratory system: (-) cough, (-) colds (-) dyspnea, (-) hemoptysis
Gastrointestinal system: (-) abdominal pain (-) diarrhea, (-) constipation, (-) melena,
(-) anorexia, (-) vomiting
Genitourinary system :(-) hematuria, (-) oliguria
Musculoskeletal system: (-) myalgia, arthralgia
Hematologic system: (-) bleeding tendencies
Endocrine- metabolic system: (-) weight loss, (-) fever (-) easy fatigability, (-)
sweating, (-) chills
PHYSICAL EXAMINATION
General 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
Height
BMI

38.5 Kg. (5th percentile)

160 cm. (25th percentile)
15.3 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 distention
Thorax 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 coherent
Cerebellar: No Nystagmus
CN:
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 - 5/5
RL - 5/5

LU - 5/5
LL 5/5

Sensory:
Pain sensation is intact 100% in all extremities
DTR:

Left
Righ
t

Brachioradial
is
2+
2+

Biceps

Triceps

2+
2+

2+
2+

Patella
r
2+
2+

planta
r
2+
2+

Meningeal sign: Negative Nuchal rigidity, Brudzinski, and Kernigs

CLINICAL IMPRESSION: Acute Post-Streptococcal Glomerulonephritis
Salient Features:
History of sore throat accompanied by cough and colds
Lower extremity and periorbital edema
Hypertension
Fever

Differential Diagnoses:
1. IgA Nephropathy
IgA 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 IN
Fever

Hypertension

RULE OUT
(-)Recurrent
episodes
of
gross
hematuria, followed by persistent
microscopic hematuria
(-)Pain in the flank

2. Tubulointerstitial Nephritis
Kidney 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 IN
Fever
Hypertension

RULE OUT
(-) Recent NSAIDS or Antibiotic use
(-) 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 IN
Facial Edema
Hypertension

RULE OUT
(-) Foamy appearance of urine
(-) 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

serum c3 conc

c3 which deposits on the GBM

Chemotactic plasma activated complement (c5a)

Platelet-derived inflammatory mediators
Cytokines and cellular immunity factors
PMN leukocytes
Inflammatory response

GBM destruction

hematuria,

dysuria
Edema of the capillary walls
glomerular capillary walls
Capillary lumen narrowed
Impedes glomerular perfusion
Oliguria
activation of the RAAS
transudation

permeability of

proteinuria
urinary protein loss
hypoalbuminemia
plasma oncotic pressure and

of fluid from IV compartment to interstitial

space
stimulates the release of ADH which
enhance the absorption of water in the collecting duct

hypertension
hypervolemia

Anasarca

nausea, headache, vomiting

hemodilution
anemia

Clinical Manifestations
-

Hematuria (gross or microscopic)

Other cardinal features of glomerular injury
o Proteinuria
o Hypertension
o Edema
o Oliguria
o Renal insufficiency

WORKUP
Urine 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.
MANAGEMENT
Supportive measures
a Bed rest and limitation of physical activities are measures in most
glomerulopathies including PSAGN.
b Dietary Na restriction is acceptable to most children, especially those with mild
affliction.
c Control of dietary protein and potassium.

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.
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 Therapy
a Loop diuretics particulary furosemide or ethacrymic acid - promote diuresis and
to treat mild to moderate hypertension.
b Diazoxide - hypotensive agent; Hydralazine
c 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.
d Sublingual and oral calcium channel blockers (nifedipine) in severe and mild to
moderate hypertension, respectively.
e ACE Inhibitors such as captopril, are currently recommended as additional
agents for mild-to-moderate hypertension.
f 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.