Presentation on theme: "Orange Urine on Halloween"— Presentation transcript:
1Orange Urine on Halloween Eva Delgado, MDMorning Report
2Overview Case Presentation Indications for Referral/Admission Work-up based on DifferentialDiscussion of PathophysiologyTreatment and PrognosisTake Home Points
3Case Presentation12 y/o F with OCD develops “orange” urine with sediment.PMD advises watchful waiting.No real symptoms – no dysuria, no abd pain, no urgency but some frequency.PMH + OCDNo known family historyNot yet menstruating.
4Case PresentationOrange urine persists x 4 days, so mom makes appointment with PMD.PMD notes elevated BP, weight gain, and then orders one key test………..URINALYSIS: + hematuria, + proteinuriaHTN with hematuria, proteinuria implies glomerular origin so need to admit – if only isolate hematuria or isolated proteinuria, would be ok to observe – also think about admitting if there is a story of casts
5A Word on UrinalysisUA with >/= 5 RBC/hpf on 3 samples over several weeks = HEMATURIAOnly UA can distinguish between confounders:Myoglobin, hemoglobin, toxins, foods/coloringBUT, if you have hematuria and proteinuria, higher likelihood of having renal disease – although you can see this with infection alone………need to look at rest of UAMassengill, Peds In Review, 2008
6A Word on Disposition Hematuria AND proteinuria Hypertension Proteinuria may be due to notable hematuria, BUT..Combination of both increases risk of renal diseaseHypertensionCan be a symptom of fluid overload warranting diuresis and further observationPMD sends patient to the ED…..Boineau and Lewy, Peds in Review, 1989.Simckes and Spitzer, Ped in Review, 1995.
7Physical Exam in ED Wt 60kg (↑ over last 6 mos) VS: T 36.4, P 68, BP 146/80, R 20, 100% O2Gen: no distressHEENT: no peri-orbital edema, MMMChest: CTA b/lCV: RRR, no murmurAbd: soft, NTNDExt: slight erythema in skin folds, no edema
8Differential and Work-Up UrinalysisChemistry panelCBCC3, C4ASO +/- Throat swabImagingDo you need a biopsy?UA – likely looking for RBC casts or dysmorphologyChem – to look for BUN/Cr and/or electrolyte anomaliesCBC – to look for anemiaC3, C4 to see if there is an immune-mediated event – WHY?ASO to look for recent strep
9Thinking of Glomerulonephritis Clues to look for in H&P:Edema, discolored urine (in 30-50%), HTN due to ↓GFR and hypervolemia, oliguriaClues to look for in UA:+ hematuria, + proteinuria, + casts (60-85%)RBC dysmorphology implies glomerular damageSensitivity 95%, specificity 90%McCory, Peds in Review, 1983.Boineau and Lewy, Peds in Review 1989.
10Glomerulopathy vs. Glomerulonephritis Nephrotic SyndromeGlomerulonephritisEdemaR = Red urine (hematuria)ProteinuriaO = OliguriaHypoproteinemiaP = ProteinuriaElevated LDLE = Elevated BP, BUNHypercoagulability (↑fibrinogen, factor V)Low C3 = Post-Strep, Membranoproliferative, SLESilverstein, Laughing your way to passing the pediatric boards, 2008.
12Poststreptococcal GN Most common type of Acute GN Usually occurs in 5-15 y/o50% of cases are asymptomaticDiagnosed by evidence of Group A StrepASO titers detectable 2-4 weeks s/p pharyngitisAnti-DNase-B titers helpful in post-pyoderma typeSimckes and Spitzer, Peds in Review 1995.
13The Role of Grp A Strep Nephritogenic strains of streptococci Wall protein M12 in pharyngitis, M49 in pyodermaThese strains pose ~ 15% risk of PSGN approx 2 weeks after initial infectionAntibiotic treatment to prevent GN?Simckes and Spitzer, Peds in Review, 1995.Rodriguez-Iturbe and Musser, J Am Soc Nephrology, 2008
14The Role of Grp A Strep PANDAS = Post-infectious Autoimmune Neuropsychiatric Disorders Associated with Streptococcal InfectionSyndenham’s Chorea and Rheumatic FeverOCD/Tic disorders shown to emerge or worsen with temporal relation to Grp A Strep infectionPANDAS patients may have higher susceptibility to Grp A Strep infection, + family h/o Rheumatic FeverKurlan et al. 121 (6): (2008) Pediatrics
15Considering the DDX of PSGN Low C380-90% of PSGN cases have low C3 x 2 mosAlso seen in GN due to SLEConsider MPGN if low C3 > 2 mosMPGN can also present after infectionMPGN may also low C4Diagnose by biopsyTRAM-TRACKING McCrory, Peds In Review, 1983.
16Considering DDX of PSGN Normal C3:IgA NephropathySuspect if recurrent hematuria with URIs/InfectionsAlport’s+ Family HistoryHUS or HSP can present with gross hematuriaPost-viral GNBoineau and Lewy Peds in Review 1989.
17Treatment of AGN in General Admit if HTN, edema, or signs of renal failureMonitor/correct electrolyte anomaliesTreat HTN to avoid sequelaeDiuresis loop diuretics like lasixFluid and salt restrictionAnti-hypertensives like the Ca-channel blockersSimckes and Spitzer Peds in Review, 1995.
18Treatment Specific to PSGN Antibiotics to target Grp A StrepCultures often positive even if no symptoms, suggesting active infectionTreatment may milder course of PSGNEpidemics of Grp A Strep may warrant ppx to prevent PSGN, especially in underdeveloped societiesUnclear/controversial role for impact on OCDRodriguez-Iturbe and Musser, J Am Soc Nephrology, 2008
19Prognosis and Sequelae Good prognosis in childrenCLOSE follow-up!HTN resolves in ~ 1-2 weeksC3 levels return to normal in ~ 6 weeksGross hematuria resolves in ~ 6 weeksMicroscopic hematuria resolves in ~ 1 yearProteinuria resolves in ~ 6 monthsProgression to renal dysfunction RAREMcCrory, Peds in Review 1983.
20Take Home Points Urinalysis is KEY test to w/u discolored urine UA with casts/dysmorphic RBCs = GNHTN, edema, or renal dysfunction admitPoststrep GN = most common, due to characteristics of Strep and/or patientTreat Strep infection and co-morbiditiesGuarantee follow-up
21Works CitedBoineau and Lewy, “Evaluation of Hematuria in Children and Adolescents,” Pediatrics in Review, 1989.Kurlan et al., “Streptococcal Infections and Exacerbations of Childhood Tics and OCD Symptoms: A Prospective Blinded Cohort Study,” Pediatrics 2008.Massengill, “Hematuria,” Pediatrics in Review, 2008.Rodriguez-Iturbe and Musser, “The Current State of Poststreptococcal Glomerulonephritis,” Journal of American Society of Nephrology, 2008.Simckes and Spitzer, “Poststreptococcal Acute Glomerulonephritis,” Pediatrics in Review, 1995.McCrory, “Glomerulonephritis,” Pediatrics in Review, 1983.