POST STREPTOCOCCAL GN

1. Case presentation
By
Dr. Muhammad Rashid
PGR WMW

2. Bio-data
• Patient, Mohammad Raza, 14 years male
resident of Gujranwala and student of 7 class.
• Presented on 5th June, 2014 in nephrology
OPD.

3. PATIENT PICTURE

4. Presenting complaints
• Sore throat for 10 days
• Cola coloured urine for 1 day
• Decrease urine output for 1 day

5. History of present illness
• My patient non-smoker, non-hypertensive and
non-diabetic was in his usual state of health
when he developed pain and irritation in
throat. It was associated with fever, low grade
not associated with rigors or chills and
relieved by panadol from local doctor. Patient
did not use any other medication except
panadol. It improved in 3 days.

6. History of present illness
• One day back patient started having cola
coloured urine. It was sudden in onset not
associated with pain or shivering but associated
with decreased output of urine. Patient noted
that urine also contains some froth. Patient
never had such episode before. Urine was never
containing fresh blood or blood clots.
• Patient also noted mild swelling of the feet up
to ankles only.

7. Systemic review
• Patient had decreased appetite and generalized
weakness and he had to give support to take him to
the washroom.
• History of decrease sleep.
• No h/o vomiting or nausea.
• No h/o bruising on skin or petechiae or rash.
• No history of weight loss, vomiting, diarrhoea, nausea
or constipation.
• No history of fits, neck rigidity, limb weakness or gait
abnormality.
• No history shortness of breath, wheezing etc.

8. Past history
• Patient has never been admitted to hospital
before in his life.

9. Personal and socio-economic history
• Patient is not a smoker
• He is student and good in studies.
• He has two siblings.
• He belongs to a low socio-economic class.

10. Drug history
• No history of hakeem medication.
• No history of any drug allergy.
• No history of any medication except panadol
for this illness.

11. Family History
• No h/o such disease in the family

12. Differential diagnosis
• Post-streptococcal GN
• IgA nephropathy
• Drug induced GN
• myoglobinurea

13. EXAMINATION

14. A young boy ill looking lying in bed, well cooperative
with branula on his right forearm
• Pulse: 78/min
• Bp: 160/100mm of Hg
• Temp: 99 F
• RR:
• Pallor +ve
• Pedal edema:+ve
• Cyanosis: -ve
• Jaundice: -ve
• Koilonychia: -ve
• Clubbing : -ve
• Lymph nodes: not palpable
• Thyroid gland : not enlarged
• Petechia: not seen
• Purpura: not seen

15. Abdominal & Genito urinary examination
• Flat abdomen, no scar mark, no striae, Genitalia
normal on inspection, abdomen moving with
breathing.
• Non tender in all quadrants, liver span is normal,
spleen not palpable.
• Kidneys not palpable.
• Shifting dullness –ve
• Fluid thrill –ve
• Bowel sounds normal.

16. RESPIRATORY SYSTEM
• Normal chest shape, no scar mark, striae, bruising,
petichiae.
• Apex beat in 5th ICS
• Trachea is central
• Chest movements are bilateral equal and chest
expansion is 6cm.
• Vocal fremitus is equal on both sides
• On percussion, it is resonant and comparable
bilaterally.
• On auscultation, NVB with no added sounds.
• Vocal resonance is equal on both sides.

17. CARDIO VASCULAR STSTEM
• Apex beat in 5th intercostal space. normal in
character. Just medial to midclavicular line
• No parasternal heave
• On auscultation, S1+ S2+ 0.

18. CENTRAL NERVOUS SYSTEM
• GCS 15/15
• PERLA +
• Higher mental functions intact
• Sensory and motor system normal
• No signs of meningeal irritation
• Cerebellar system is intact
• All Cranial nerves are intact

19. • WBC 9*103
• HB 8.0g/dl
• Plt 422*103
• Blood urea 40
• S.creatinine 1.0
• Na +:138 K+:3.7
• ALT 27
• AST 32
• Serum albumin 3.4
• Urine C/E
• Protein ++
• Blood +++
• Pus cells 4-5
• aso titre >200
Investigations

20. investigations
• Complement levels : Low complement levels
• Anti-hcv : non reactive
• HBsAg : non reactive
• RA: -VE
• ANA: -VE

21. Diagnosis after investigations
• POST STREPTOCCOCAL GN

22. TREATMENT STARTED
• Conservative treatment planned for
Main aims were
>BP control,
>Salt and water restriction,
>anemia correction, and
>fluid and electrolytes replacement

23. • Patients RFTs rapidly worsen over 3 to 5 days
• Repeated RFTs urea 110, s. creatinine 6.0
• Urine output further deteriorated and patient
become anuric
• Renal biopsy was planned to rule out rapidly
progressive glomerulonephritis.

24. • Patient started having uremic symptoms and
he had to undergo 4 sessions of dialysis in
next 10 days.

25. Renal biopsy
• Immunofluorescent staining demonstrates
nonspecific granular immune deposits
• Confirming type II RPGN

26. What are the various uremic
symptoms that you will see in your
patient?

27. • Anorexia, Nausea, vomiting and diarrhoea
• Shortness of breath
• Muscle weakness
• Restless leg syndrome
• Encephalopathy
• Uremic Froth
• Platelet dysfunction leading to bleeding
• Anemia
• Pericarditis

28. What will be the length of first dialysis
session?
a. 1 hr
b. 2 hrs
c. 3 hrs
d. 4 hrs
e. 5 hrs

29. Why patient has deteriorated ?

30. What will be the findings you are
expecting in renal biopsy report?

31. • His renal biopsy showed type II rapidly
progressive glomerulonephritis
• CRESCENT formation between the bowman s
capsule and glomerular tuft
• Immune complex deposition in basement
membrane

32. What treatment options you will have
now?

33. • Pt was put on deltacortril and on pulse
therapy of cyclophosphamide.

34. What will be the possible side effects
of cyclophosphamide and how to
prevent the side effects

35. • Haemorrhagic cystitis
• Hair loss
• Vomitin,diarhea
• Mouth sores
• Weight loss
• Leukopenia,anemia,thrombocytopenia
• Suppress immune system leading to fatal infections
• Allergic reactions
• Nephrotocicity
• Male infertility,female premature menupause

36. > Adequate fluid intake,
Avoidance of nighttime dosage,
Mesna (sodium 2-mercaptoethane sulfonate),
a sulfhydryl donor which binds and detoxifies
acrolein.
LEUPROLIDE used to prevent premature
menopause in females

37. What will be the dose and how to give
cyclophosphamide?

38. MANAGEMENT OF RPGN
2 phases of treatment
1. INDUCTION THERAPY
>IV METHYL PREDNIDOLONE IG for 3 days
>followed by prednisolone 1mg/kg for 10-14
days.
>then pulsed cyclophosphamide 1 g every
month for 6 months

39. • 2. MAINTANANCE PHASE
Low dose steriod and azathioprine are
continued for further 12-18 months

40. • Patient’s uremic symptoms improved with
dialysis sessions and urine output also
improved after 10 days of treatment.
• Patient was transfused twice during this stay
• At 11th PAD, patient’s attendant noticed that
patient is not moving his right half of body.
• It was then confirmed on clinical examination
that power in right leg is 3/5 and right arm is
2/5. Right planter is upgoing.

41. • As patient was already on prophylactic
anticoagulant, so it was stopped immediately
and CT scan is planned.

42. Why patient suffered weakness?

43. Why patient was getting prophylactic
anti-coagulation?

44. Why anti-coagulation was stopped
immediately?

45. What will be the differential diagnosis
regarding weakness at this point in
time?

46. • Thromboembolic phenomenon causing
Ischemic stroke
• Haemorrhagic CVA d/t anticoagulation
• Cyclophosphamide induced neutropenia
leading to brain Infections
• SOL

47. • CT scan came out to be normal.
• Showing no hemorrhage or ischemic infarct.

48. • Anti-coagulation is restarted and MRI is
planned.

49. • Weakness was static and did not fluctuate or
improved.
• Patient is also drowsy and GCS is 13/15.

50. • MRI brain was done after 3 days and its
reporting came after 2 days.
• MRI showed two contrast enhancing lesions in
left sided hemisphere and which are reported
as aspergiloma.

52. Why patient suffered from
aspergiloma?

53. Was it related to our treatment?

54. How to manage now?

55. • Amphotericin B
• Test dose 1mg IV infused over 20-30 min
• Load 0.25-0.5mg/kgIV over 2-6 hours
• Maintenance 0.25-1mg/kg iv

56. What are possible side effects of
amphotericin B?

57. • Anorexia
• Headache
• Hypokalemia, hypomagnesemia
• Hypotension
• Nephrotoxicity
• Flushing
• Leukocytosis
• Bone marrow suppression

58. Follow up
• Amphotericin B was started and
immunosuppressant therapy was continued.
• After 10 days patients RFTs returned to the
normal value and double lumen was removed as
no further dialysis was required.
• Adequate urine ouput and normal urine
complete was achieved.
• With further 15 days of amphotericin B therapy,
conscious level and weakness improved.

59. Type Percentage of RPGN Cases Causes
Type 1: Anti-GBM antibody–mediated ≤ 10% Anti-GBM GN (without lung
hemorrhage*)
Goodpasture syndrome (with lung
hemorrhage)
Type 2: Immune complex ≤ 40% Postinfectious causes:
•Antistreptococcal antibodies (eg,
poststreptococcal GN)
•Infective endocarditis
•Vascular prosthetic nephritis
•Viral hepatitis B infection
•Visceral abscess or sepsis
Connective tissue disorders:
•Anti-DNA autoantibodies (eg, lupus nephritis)
•IgA immune complexes (eg, immunoglobulin
A–associated vasculitis GN, formerly Henoch-
Schönlein purpura GN)
•Mixed IgG-IgM cryoglobulins (eg,
cryoglobulinemic GN)
Other glomerulopathies:
•IgA nephropathy
•Membranoproliferative GN
Type 3: Pauci-immune ≤ 50% Eosinophilic granulomatosis with polyangiitis
(Churg-Strauss syndrome)
Pulmonary necrotizing granulomas (eg,
granulomatosis with polyangiitis)
Renal-limited disease (eg, idiopathic crescentic
GN)
Systemic necrotizing arteritis (eg, polyarteritis
nodosa)
Type 4: Double-antibody positive Rare Same as for as types 1 and 3
Idiopathic Rare No clear cause