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Intern Seminar

Intern Seminar. Presented by Int. 吳志勳 Instructed by VS. 邱元佑. 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). Present Illness .

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Intern Seminar

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  1. 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 13.528 1.1 26 32 143 4.4 113 CA P 8.3 4.7

  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 1.0 MG/DL BIL NEGATIVE MG/D ERY 200 /UL WBC 6-8 /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 2.5 4.9 → hold albumin → keep lasix using

  10. Lab (1/19) IgA 148 mg/dl C3L 21.0 mg/dl C4 N 19.3 mg/dlASLOH 500 IU IgG 841 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) AC 79 79.5 76 73 U 1440 2960 2750 SBP 151-163 142-153 136-166 146-155 DBP 100-107 71-110 85-115 87-96

  14. Lab (24 hr urine) 3542 mL/24h under lasix 1 A’ q12h CREAL 26.6 mg/dL 800-2000 TP721 mg/dL Ccr 95.6 ml/min per 1.73 m2

  15. WBC 9.9 (1/18) 10 (1/19) • CRP 13.5 (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. 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)

  26. 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

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

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

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

  30. Prognosis • 92~98% recover completely • GFR 10~14 days • Gross hematuria 2~3 wks • BUN/Cr 1~4 wks • C3 6~8 wks • Proteinuria 3~6 months • Microscopic Hematuria months to years

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

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

  33. 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

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