Journal of Nephrology & Renal Therapy Category: Clinical Type: Research Article
Observation on Clinicopathological Profile of Post-Infectious Glomerulonephritis
- Mangal Charan Murmu1*, Arakhita Swain1, Saroj Kumar Satpathy1
- 1 Department Of Paediatrics, SCB Medical College & Hospital, Cuttack, Odisha, India
*Corresponding Author:Mangal Charan Murmu
Department Of Paediatrics, SCB Medical College & Hospital, Cuttack, Odisha, India
Received Date: Jun 07, 2017 Accepted Date: Aug 19, 2017 Published Date: Sep 04, 2017
Methods: It’s a direct prospective study done in the Paediatric Department of SCB Medical college, Cuttack, Odisha, India.
Results: Most common predisposing factor was scabies along with other infected skin lesion. Most patients had diminished complement level.
Conclusion: Post streptococcal glomerulonephritis is the most common type of glomerulonephritis in childhood. Decreased Serum C3 level is the one of predictor of PSGN.
CRP: C-Reactive Protein
C3: Complement 3
ESR: Erythrocyte Sedimentation Rate
HSP: Henoch-Schonlein Purpura
PSGN: Post Streptococcal Glomerulonephritis
RBC: Red Blood Cell
SLE: Systemic Lupus Erythematosus
WBC: White Blood Cell
CLINICAL CASE REPORT
She had been regularly attending the antenatal consultations with no risk factors identified. Her prenatal laboratory results were unremarkable except for GBS-unknown. She had three normal obstetric ultrasounds (one of each trimester); her blood type was A+. Pregnancy was uneventful with no history of vomiting, blood loss or abdominal trauma.
On admission at the delivery unit, the obstetric ultrasound revealed no fetal movements with the presence of heart beat. The Cardiotocograph (CTG) was not tranquilizing as it showed prolonged deceleration and reduced variability with pathological trace that suggested a sinusoidal pattern and, as a result, an emergent caesarean section was performed (Figure 1).A baby boy was born weighing 2610g. The newborn had a circular of the umbilical cord around the arms. On examination at birth, he was markedly pale and hypotonic with respiratory depression. Orothracheal intubation and connection to mechanical ventilation was immediately performed. He responded well and was extubated 4 minutes after and transferred to the neonatal unit with oxygen directly to his face, for further evaluation and management. The Apgar score was 5/8/8.
Initial blood gas from the umbilical cord revealed pH 7.27, pCO2 50.6 mm Hg, Hemoglobin 4.4, g/dL, bicarbonate 21.9 mmol/L and lactates 5.8 mmol/L. Laboratory exams revealed 4.0 g/dL of hemoglobin, white blood cell count of 47.700/10 EXP 9/L with 22.7% neutrophils (10.800), platelets count 183.000/10 EXP 9/L, DHL 680 UI/L, CK 190 UI/L. Further laboratory evaluation was unchanged (bilirubin, cardiac enzymes and C reactive protein). Coombs test and viral serology for Parvovirus B19 and Cytomegalovirus were negative. Hemoglobin electrophoresis showed a presence of 5% fetal hemoglobin on mother’s blood. Kleihauer-Betke test was performed, since it is a more specific exam and quantifies the amount of blood transfusion. It revealed 17.8% of fetal red cells in maternal circulation, which corresponds to a volume of approximately 890 mL of fetal blood based on the formula: (% of fetal cells determined by Kleihauer-Betke test/100) X 5000 mL = volume of FMH (in mL)  and also according to the fact that 1% of fetal erythrocytes in maternal circulation is equivalent to a fetal hemorrhage of 50mL .
Two red blood cell transfusions were made and at 12 hours of life his hemoglobin was 13.3 g/dL, white blood cells count of 10.100/uL (Neutrophils: 64.4%), platelets count of 219.000/uL and erythroblasts 87/100 leucocytes.
The outcome was favorable with hemodynamic and respiratory stability and absence of abnormal movements. Cranial ultrasonography showed, in the 3rd day of life, frontal bilateral parenchymal hyperechogenicity, was not present on 11th day of life as the ultrasounds were made by two different physicians. The authors admit that the hyperechogenicity have not been valorized by the second physician.
Follow-up at 2 and 4 months revealed a normal physical and neurological examination.
|Age in years||Male||Female||Total||Percentage|
|Less than 3 years||2||1||3||5.35|
|3 to 8 years||24||10||34||60.71|
|Latent period||Sore throat||Pyoderma||Total|
|Less than 7 days||-||-||-||-||-||-|
|More than 21 days||-||-||8||14.58||7||14.58|
|Symptoms||Number of cases||Percentage|
|Puffiness of face||53||94.64|
|Headache and vomiting||14||25.00|
|Presenting signs||Number of cases||Percentage|
|Congestive cardiac failure||7||12.50|
|Acute renal failure||3||5.35|
The most common sign in PSGN in our study was hypertension (75%) followed by oedema (60.71%) congestive cardiac failure was seen in 12.50% of cases.
|Urine examination finding||Number of cases||Percentage|
|Albuminuria Trace + ++ +++ ++++||42415103||7.1442.8526.7817.855.35|
|Heamaturia Gross Microscopic||3256||57.14100|
|Pus cell(more than 5/HPF)||18||32.14|
|CastRBC CastGranular castHyaline cast||18129||32.1421.4216.07|
|Urine Culture Positive KlebsillaE. ColiAcenetobacter||9531||16.078.925.351.78|
|Examination finding||Number of cases||Percentage|
|ASO TiterPositive (Total)PharyngitisPyodermaNo infection||261376||46.4250.0026.9223.07|
|Low Complement 3 levelPositive Negative||497||87.5012.50|
|Organism isolated||Number of cases||Percentage|
|Throat SwabNo growthGroup A Beta haemolyticStreptococciKlebsiella||65 3||42.8535.71 21.42|
|Skin swabNo growthGroup A Beta haemolyticStreptococci Staphyllococcus aureus||1511 8||44.1132.35 23.52|
Atypical presentation like hypertensive encephalopathy was seen in 2.85% of cases where as Puri et al.,  have encountered 8.8% of cases having hypertensive encephalopathy. We have seen 7.14% of patient having convulsion where as Strauss and welt et al.,  reported 5% of PSGN cases having convulsion. Acute renal failure was observed in 5.35% of cases with PSGN in our study. Our finding is consistent with the finding of Earle DP et al.,  and Sharma BK et al., , who found prolonged oliguria in 5-13% of cases but differ from the study done by Manhas et al., , who have reported 1.4% cases with anuria. Puri et al.,  have reported 14.3% cases with ARF. Chugh et al.,  reported 9.8% incidence of ARF due to PSGN. Papiloedema was seen in 2.85% of cases of PSGN. These cases were associated with convulsion and hypertensive encephalopathy. Similar finding was observed by Manhas et al., .
In our study ESR was raised in 87.50% of cases. Manhas et al.,  reported raised ESR in 56.6% of cases of PSGN. Puri et al.,  and Berry et al.,  found raised ESR in about 95% of cases of PSGN. This is at par with our finding. CRP was raised in 17.14% of cases. Valyasevi A et al.,  reported raised CRP in 15.38% of PSGN. Puri et al.,  reported it to be raised in much higher percentages of cases.
In our study 46.42% of cases of PSGN had ASO positive. Out of which 50% had pharyngitis and 26.92% had pyoderma. Leung DT et al.,  in Hong Kong had shown that 78% of PSGN in children had elevated ASO titer more than 200IU/L. Puri et al.,  have found a raised titer in 75% cases. Rajajee et al.,  have not found significant raised in ASO titer like our study with pyoderma. Wannamaker LW et al.,  have found feeble ASO response in patients with pyoderma induced nephritis.
Complement 3 level was positive in 49 patients (87.50%). Popovic-Rolovic M et al.,  had found low complement C3 level. Shroff KJ et al.,  found low complement C3 level in 88% of patients. Federic strife et al.,  and Vijaykumar M et al.,  found hypocomplementemia in about 90% of patient with PSGN. Complete recovery was seen in 89.28% of cases of PSGN, 5 patients (8.92%) were discharged on request (latter on followed up), one patient died (1.78%) in hospital (after all investigation were done) due to associated sepsis with hypertensive encephalopathy. Puri et al.,  found mortality rate of AGN to be 1.4%. Devid Charles et al.,  and Berry S et al.,  found mortality to be 1%. Our finding is consistent with their findings. Renal biopsy was done in all 3 cases who developed renal failure, it showed the futures of PSGN.
PSGN in children was presented more in males than females. Most common age group was 3 to 8 years. Most common preceding infection was infective scabies along with other infected skin lesions. Preceding history of Pharyngitis was found in fewer cases. Latent period between preceding infection and onset of disease varies from 8 to 30 days. The patients with sore throat had shorter latent period than that with skin lesions. Oliguria, facial puffiness, pedal edema, hematuria and hypertension were the most common mode of presentation of the disease, observed in this study. Microscopic hematuria and proteinuria were invariably present in all cases. RBC cast in urine was found in about 1/3rd of cases. Most of the patients with PSGN had diminished complement 3 levels, majority of which return to normal on follow-up after 8 weeks. Beta-hemolytic streptococci were isolated from either skin or throat swab in 1/3rd of patient studied. All most all cases recovered completely within two to three weeks of admission. Mortality from the disease was very low.
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|Cast||Culture||Hb(gm/dl)||TLC/cmm of blood||ESR mm fall in !st hour||ASO||CRP||Blood urea (mg/dl)||Serum creartinine (mg/dl)||Serum cholesterol (mg/dl)||Serum Sodium (meq/l)||Serum Potassium(meq/l)||Serum C3 level (mg/dl)||Throat swab/skin swab culture||CXR/Xray KUB||Outcome|
Citation:Murmu MC, Swain A, Satpathy SK (2017) Observation on Clinicopathological Profile of Post-Infectious Glomerulonephritis. J Nephrol Renal Ther 3: 014.
Copyright: © 2017 Mangal Charan Murmu, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.