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Pediatrics MorningReport
Whats with this Back Pain?!?
Judy Vu, MD
Med-Peds PGY4December 13, 2013
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History of Present Illness
S 14 y/o previously healthy white girl p/w bilateral back pain
S Achy in mid back, progressed to lower back, nagging pain
S Rated 5-8/10, duration ~4 days, no real exacerbating or relievingfactors
S Recalls back soreness ~1 week ago after raking a lot of leaves inthe backyard, resolved quickly and now returned
S Decreased appetite and PO intake over the same timeS NBNB emesis through the night4 nights ago
S PCP evaluation the next morning (3 days prior to presentation)
S CXR negative
S Zofran prescribedhelped until morning of presentation
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Additional History
S Allergies: Decadronagitation and mood changes
S Meds: PRN albuterol, PRN Zofran, PRN ibuprofen x2 for backpain. PRN Midol or ibuprofen for menstrual cramps. Advil + Alevein large amounts 3 months ago after ACL tear.
S PMH: No chronic illnesses, hospitalizations, or UTIs. Menstrualcycles normallast 1 week ago. UTD on immunizations
S PSH: Tonsillectomy & adenoidectomy, thumb surgery
S Fam Hx: No chronic conditions. Maternal aunt with renal stones.
S Soc Hx: Lives with parents and sibs. Sister sick with URI. Attends9thgrade, enjoys school. No EtOH, tobacco, or other illicits.
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Physical Exam
VS: T 37.1, HR 70, RR 14, BP 118/77, Sat 100% on RAGEN: Tired but non-toxic, lying in bed wrapped in blankets,
pleasant, cooperative, NAD
HEENT: NCAT, EOMI, no conjunctival injection, ears wnl, NP
clear, no OP erythema or lesions, MMM/pink
Neck: supple with full ROM, shotty LAD
CV: RRR, nl s1 and s2, no murmur/gallop, normal pulses, CRT mid-back. Nodistinct CVA tenderness.SKIN: No rashes, mottling, jaundice
NEURO: A&O x4, face symmetric, grossly normal strength/tone,
normal reflexes.
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One Liner Synopsis
14 year-old previously healthy girl with 4 days of progressive
lumbar back pain, anorexia/decreased appetite, intermittent
nausea, NBNB emesis, intermittent fevers
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Differential Diagnosis
S Renal
S Acute renal failure
S Dehydration
S
NSAID useS GN: RPGN, Crescentic
S Tubulointerstitial: ATN, AIN
S Post-obstructive
S Chronic kidney disease
S Infectious
S UTI
S Pyelonephritis
S Paraspinal abscess
S Osteomyelitis
S POTS/TB
S MSK
S Muscle sprain/spasm
S Rhabdomyolysis
S Bruised boneS Vertebral fracture
S Heme/Onc
S Osteosarcoma
S Myosarcoma
S Multiple myeloma
S Rheumatology/Immunology
S Lupus
S Ankylosing spondylitis
S Juvenile Idiopathic Arthritis
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Initial Evaluation
S Received 1 L NS
S LFTs wnl, lipase 181
SInflammatory Markers: CRP 4.1 and ESR 47
S UA: SG >1.030, pH 5, cloudy, large Hgb, neg nitrite,small LE, trace ketones.Micro: >30 WBC, >30 RBC, >30 epi, 3+ bacteria, >30
hyaline casts, 5 WBC casts
8.8
12
35 209
13B, 47N, 32L, 8M
146 102
794.6 19 8.14
7.7
84
1.6
3.1
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S Renal Ultrasound:
SRight length 11.3 cm
S Left length 11.2 cm
S Normal 8.8-11.9 cm for agerange
S No obstructive uropathy
S Subtle parenchymalechogenicity in both kidneys
S Micro: + beta-hemolytic GAS
S ASO titer: 219, Dnase B: 286
S C3/C4 levels: 11 / 13
S Anti-glomerular basementmembrane Ab: negative
S MPO/PR3 Antibody: 1 / 0
S ANA: None
S ds DNA: negative
S ANCA:
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Renal Biopsy
S Exudative glomerulonephritis
most consistent with post-
infectious glomerulonephritis
S IgG and C3 staining on IF
S Subepithelial humps on EM
S EM: Subepithelial humps
easily identified, rare
mesangial deposit.
Segmental effacement of
podocyte foot processes. No
crescents.
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Patients Clinical Course
S Patient continued to have symptomatic uremia,hyperkalemia, hyperphosphatemia
SIntermittent hemodialysis started on hospital day #3 x 1week
S BUN 44, Cr 1.63 after 11 days of hospitalization
S Fluid restriction 2.5 L, renal diet (LOW Na, K, Phos)
S Pulse Solu-Medrol PO prednisone
S Hypertensiveamlodipine started at time of discharge
S PRN Lasix for edema or weight gain >2 pounds
S NO NSAIDs!!!
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Complication of - hemolytic
GAS
Nonsuppurative
S PANDAS
S Poststreptococcalglomerulonephritis
S Poststreptococcal reactive
arthritis
S Rheumatic fever
S Sydenhams chorea & other
autoimmune movement
disorders
Suppurative
S AOM, PNA, sinusitis
S Cervical lymphadenitis
S Peritonsillar or retropharyngeal
abscess
S Bacteremia, toxic shock
S Endocarditis
S Fasciitis/myositis
S Meningitis
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Complication of - hemolytic
GAS
S Complication arise predominantly from pharyngitis and
scarlet fever
S Abx reduce severity of acute sx & shorten illness by 1 day
S >90% of treated & untreated pts with acute pharyngitis are
symptom-free by day #7 of illness
S Primary reason for treating uncomplicated strep
pharyngitis?
S Reduce incidence of subsequent rheumatic fever
S Reduce recurrence rate of infection
S Unclear if abx tx reduces risk of APSGN
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Acute Poststreptococcal GN
(APSGN)
S Leading cause of acute nephritic syndrome
S SporadicS Most frequent in ages 2-6
S Recent hx of pharyngitisin winter months
S Rash+ poor personal hygiene in warmer climate
S Occurs 10 days after pharyngitis OR 2 weeks after skininfxn
S Nephritogenic strain of GAS
S Immunity is type-specific & long-lasting! Repeatinfections
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S Dx based on clinical hxand serologies!S No need for biopsyespecially in children with typical hx
S Urinalysis and RFP
S RBC casts, proteinuria, WBCmay be misdiagnosed as
UTI!!!S Abnormalities may persist up to 6-12 months
S Mild hypoalbuminemia, if any
S Signs of inflammation
S CBCS Leukocytosis with neutrophilia
S Mild normochromic normocytic anemia (dilutional)
S ESR & CRP
S Elevated early
S Effective for monitoring diseaseif either returns to normal afterstopping treatment, the attack is usually over
Diagnosis: APSGN
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Diagnosis: APSGN
S Evidence of preceding streptococcal infection based on
serologies
S Antistreptolysin O titer (ASO)
S ASO peaks at ~4-5 wks, first noted during 2ndor 3rdwk of acute
episode
S Peak titer at time of onset TRUE infxn rather than transient carrier!
S Antideoxyribonuclease B (DNase B)more specific, $$
S Throat cultures often negative by the time APSGN appears
S Complement levelsS VERY LOW C3 and minimal decrease in C4
S LOW C3 and LOW C4 Lupus
S Normal complementIgA nephropathy
S
NO NEED to check CH50a historical thingS Timely measurement!! Typically C3 normalizes in 6-8 weeks!!!
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Course: APSGN
S Prognosis is GOOD!!!
S
>95% of pts recover spontaneously. Self-limitedS Return to baseline renal function within 3-4 weeks w/o
long-term sequelae
S Best indicator of resolved dz: C3 back to normal
S Biopsy indicated if
S Delayed resolution
S Severe renal failure at onset
S Progressive renal failure
S Systemic featurerash, arthralgias, HSM, persistent fevers
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Treatment: APSGN
S Can be managed in primary care setting
S Symptomaticdiuretic & anti-hypertensive if necessary
S Fluid restriction if edemaS Renal diet depending on clinical scenario
S Remember to check BPs and RFP
S HTN & azotemia usually subside in 1-2 wks
S Refer immediately to pediatric nephrologist
S Severe HTN, >99%ile
S Renal insufficiency.
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References
S Hahn RG et al. Evaluation of Poststreptococcal Illness. AAFP2005;71:1949-54.
S Simckes AM, Spitzer A. Poststreptococcal AcuteGlomerulonephritis. Pediatrics in Review 1995;16;278
S Welch TR. An Approach to the Child with AcuteGlomerulonephritis. International Journal of Pediatrics.2012
S http://www.nlm.nih.gov/medlineplus
S http://www.niddk.nih.gov/