Pass Medicine 42
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Transcript of Pass Medicine 42
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An 18 year old male presented to the Emergency Department complaining of blood in his urine for the last
day. He described it initially as few drops of dark blood at the end of micturition but has gradually
worsened such that at the time of admission he was passing large amounts of cola coloured urine. He also
complained of swollen ankles and puffy eyes developing over the last few hours and had been feeling
increasing lethargic and unwell over the last two days. When questioned specifically he denied the
presence of shortness of breath, chest pain, haemoptysis, previous haematuria or change in urine volume
and had otherwise been well in himself. He had no previous renal problems, though he recalled that his
brother had been prescribed a course of steroids when he was aged nine years old for leaky kidneys. Other
than a one week course of phenoxypenicillin 500mg QDS prescribed by his GP two weeks ago for tonsillitis
and a one week course of amoxicillin 500mg TDS prescribed 6 months ago for acute sinusitis he had no
drug history and no past medical history of note.
Examination revealed the presence of a young athletic male with a blood pressure of 162/84 mmHg, heart
rate of 96bpm, respiratory rate of 18/min, oxygen saturations of 95% on air and temperature of 37.1
Celsius. Examination of the cardiovascular system revealed the presence of normal heart sounds, a JVP of
3cm and the presence of bilateral pitting oedema of his ankles. Examination of his respiratory system was
unremarkable with no signs of respiratory distress. Examination of his gastrointestinal system was
unremarkable. Examination of his face revealed the presence of bilateral periorbial oedema; examination
of his ENT and neurological systems were both unremarkable.
Initial investigation revealed the following results:
Hb 13.2 g/dl
Platelets 428* 10 /l
WBC 14.2 * 10 /l
ESR 26 mm/hr
Na 138 mmol/l
K 5.2 mmol/l
Urea 6.4 mmol/l
Creatinine 77 µmol/l
CRP 18 mg/l
Bilirubin 18 µmol/l
Question 15 of 71
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ALP 82 u/l
ALT 21 u/l
Protein 78 g/l
Albumin 39 g/l
CXR: normal appearance of heart and lung fields
ECG: sinus tachycardia 108bpm
Urinalysis: blood ++++ protein ++++, ketones +, negative all other parameters
Urine MCS: awaiting result
Blood MCS: awaiting result
What is the most likely diagnosis?
Rapidly progressive glomerulonephritis
Berger's nephropathy
Wegner's granulmatosis
Post streptococcal glomerulonephritis
Membraneous nephropathy
This gentleman has developed post streptococcal glomerulonephritis (PSGN), an immune mediated
reaction in response to the presence of specific strands of Streptococcus spp. The latent period is
classically one to two weeks post infection and presents with an acute glomerulonephritis characterised
by haematuria (with dark urine owing to the haemolysis of red blood cells that have penetrated the
glomerular basement membrane), proteinuria, oedema with or without oliguria. A key differential diagnosis
is Berger's nephropathy, the most common form of adult glomerulonephritis. This tends to present one to
two days post a non specific upper respiratory tract infection and is characterised predominantly by
haematuria, with an usually excellent prognosis. Rapidly progressive glomerulonephritis is associated witha rapid decline of renal function but may present with similar features to PSGN, whilst membraneous
nephropathy is characterised by a nephrotic syndrome.
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Post-streptococcal glomerulonephritis
Post-streptococcal glomerulonephritis typically occurs 7-14 days following a group A beta-haemolytic
Streptococcus infection (usually Streptococcus pyogenes). It is caused by immune complex (IgG, IgM and
C3) deposition in the glomeruli. Young children most commonly affected.
Features
general: headache, malaisehaematuria
nephritic syndrome
hypertension
low C3
raised ASO titre
Renal biopsy features
post-streptococcal glomerulonephritis causes acute, diffuse proliferative glomerulonephritis
endothelial proliferation with neutrophilselectron microscopy: subepithelial 'humps' caused by lumpy immune complex deposits
immunofluorescence: granular or 'starry sky' appearance
Carries a good prognosis
(http://d32xxyeh8kfs8k.cloudfront.net/images_Passmedicine/usb072b.jpg)
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Proliferation of endothelium and mesangium with recruitment of
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neutrophils. Tubules are normal
(http://d32xxyeh8kfs8k.cloudfront.net/images_Passmedicine/usb073b.jpg)
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Subepithelial humps on the outside of the basal membrane
(http://d32xxyeh8kfs8k.cloudfront.net/images_Passmedicine/usb074b.jpg)
© Image used on license from
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Electron microscopy. Numerous neutrophils (blue arrows) and
subepithelial humps (red arrows)
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