Master the board step 3

Pediatrics
Hematuria
Acute Poststreptococcal Glomerulonephritis (APGN)
A 10-year-old boy presents with lower extremity swelling. He has had a sore
throat for 2 weeks and fever. His mother has noticed very dark, brownish-red
urine over the past couple of days. He has no known allergies. On physical examination,
his blood pressure is 185/100 mm Hg. Which of the following is indicated
for management?
a. ACE inhibitors
b. Diuretics
c. Erythromycin
d. Oral prednisone
e. Penicillin
Answer: E. The most appropriate therapy for APGN is antibiotics to eradicate the
underlying infection. Penicillin is the drug of choice. Erythromycin is used on patients
who are penicillin-allergic.
APGN presents in children 5–12 years old, 1–2 weeks after strep pharyngitis
or 3–6 weeks after skin infection (impetigo). The classic triad of symptoms is
edema, hypertension, and hematuria.
Diagnostic Testing
··
Urinalysis: RBCs, RBC casts, protein, polymorphonuclear cells
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Low C3 (Returns to normal in 6–8 weeks.)
··
Need positive throat culture or increasing antibody titer to streptococcal
antigens
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Most specific test: Anti-DNase antigen
Treatment
··
Penicillin (erythromycin if penicillin-allergic)
··
Supportive care: Sodium restriction, diuresis, fluid and electrolyte management
··
Antihypertensives are not indicated in acute management.
··
Steroids do not have a role in management.
There is complete recovery in > 95 percent of patients.
Other Conditions Presenting with Hematuria
· · IgA nephropathy (Berger’s disease): This is the most common chronic
glomerular disease worldwide. It can present in adolescents but most commonly
presents in a patient in her 20s or 30s with gross hematuria after
upper respiratory infection or gastrointestinal infection. There will be
mild proteinuria and hypertension and a normal C3 on lab workup. The
most important step in management is blood pressure control.
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