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Orange Urine on Halloween Eva Delgado, MD Morning Report.

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Presentation on theme: "Orange Urine on Halloween Eva Delgado, MD Morning Report."— Presentation transcript:

1 Orange Urine on Halloween Eva Delgado, MD Morning Report

2 Overview Case Presentation Case Presentation Indications for Referral/Admission Indications for Referral/Admission Work-up based on Differential Work-up based on Differential Discussion of Pathophysiology Discussion of Pathophysiology Treatment and Prognosis Treatment and Prognosis Take Home Points Take Home Points

3 Case Presentation 12 y/o F with OCD develops “orange” urine with sediment. 12 y/o F with OCD develops “orange” urine with sediment. PMD advises watchful waiting. PMD advises watchful waiting.

4 Case Presentation Orange urine persists x 4 days, so mom makes appointment with PMD. Orange urine persists x 4 days, so mom makes appointment with PMD. PMD notes elevated BP, weight gain, and then orders one key test……….. PMD notes elevated BP, weight gain, and then orders one key test……….. URINALYSIS: + hematuria, + proteinuria URINALYSIS: + hematuria, + proteinuria

5 A Word on Urinalysis UA with >/= 5 RBC/hpf on 3 samples over several weeks = HEMATURIA UA with >/= 5 RBC/hpf on 3 samples over several weeks = HEMATURIA Only UA can distinguish between confounders: Only UA can distinguish between confounders: Myoglobin, hemoglobin, toxins, foods/coloring Myoglobin, hemoglobin, toxins, foods/coloring Massengill, Peds In Review, 2008

6 A Word on Disposition Hematuria AND proteinuria Hematuria AND proteinuria Proteinuria may be due to notable hematuria, BUT.. Proteinuria may be due to notable hematuria, BUT.. Combination of both increases risk of renal disease Combination of both increases risk of renal disease Hypertension Hypertension Can be a symptom of fluid overload warranting diuresis and further observation Can be a symptom of fluid overload warranting diuresis and further observation Boineau and Lewy, Peds in Review, Simckes and Spitzer, Ped in Review, PMD sends patient to the ED…..

7 Physical Exam in ED Wt 60kg ( ↑ over last 6 mos) Wt 60kg ( ↑ over last 6 mos) VS: T 36.4, P 68, BP 146/80, R 20, 100% O2 VS: T 36.4, P 68, BP 146/80, R 20, 100% O2 Gen: no distress Gen: no distress HEENT: no peri-orbital edema, MMM HEENT: no peri-orbital edema, MMM Chest: CTA b/l Chest: CTA b/l CV: RRR, no murmur CV: RRR, no murmur Abd: soft, NTND Abd: soft, NTND Ext: slight erythema in skin folds, no edema Ext: slight erythema in skin folds, no edema

8 Differential and Work-Up Urinalysis Urinalysis Chemistry panel Chemistry panel CBC CBC C3, C4 C3, C4 ASO +/- Throat swab ASO +/- Throat swab Imaging Imaging Do you need a biopsy? Do you need a biopsy?

9 Thinking of Glomerulonephritis Clues to look for in H&P: Clues to look for in H&P: Edema, discolored urine (in 30-50%), HTN due to ↓ GFR and hypervolemia, oliguria Edema, discolored urine (in 30-50%), HTN due to ↓ GFR and hypervolemia, oliguria Clues to look for in UA: Clues to look for in UA: + hematuria, + proteinuria, + casts (60-85%) + hematuria, + proteinuria, + casts (60-85%) RBC dysmorphology implies glomerular damage RBC dysmorphology implies glomerular damage Sensitivity 95%, specificity 90% Sensitivity 95%, specificity 90% McCory, Peds in Review, Boineau and Lewy, Peds in Review 1989.

10 Glomerulopathy vs. Glomerulonephritis Nephrotic Syndrome Glomerulonephritis Edema R = Red urine (hematuria) Proteinuria O = Oliguria Hypoproteinemia P = Proteinuria Elevated LDL E = Elevated BP, BUN Hypercoagulability ( ↑ fibrinogen, factor V) Low C3 = Post-Strep, Membranoproliferative, SLE Silverstein, Laughing your way to passing the pediatric boards, 2008.

11 Laboratory Results UA: 3+ blood, 2+ protein, 1+ LE, 0 nitrites, UA: 3+ blood, 2+ protein, 1+ LE, 0 nitrites, WBC, numerous RBC, 1-3 granular casts Chemistry: BUN/Cr = 17/0.8 Chemistry: BUN/Cr = 17/0.8 CBC: Hbg 11.3, HCT 32.5, MCV 79 CBC: Hbg 11.3, HCT 32.5, MCV 79 C3: 26 (86-184) C3: 26 (86-184) C4: 21.5 (20-59) C4: 21.5 (20-59) ASO: 2130 (<400 unit/ml); and + Rapid strep ASO: 2130 (<400 unit/ml); and + Rapid strep

12 Poststreptococcal GN Most common type of Acute GN Most common type of Acute GN Usually occurs in 5-15 y/o Usually occurs in 5-15 y/o 50% of cases are asymptomatic 50% of cases are asymptomatic Diagnosed by evidence of Group A Strep Diagnosed by evidence of Group A Strep ASO titers detectable 2-4 weeks s/p pharyngitis ASO titers detectable 2-4 weeks s/p pharyngitis Anti-DNase-B titers helpful in post-pyoderma type Anti-DNase-B titers helpful in post-pyoderma type Simckes and Spitzer, Peds in Review 1995.

13 The Role of Grp A Strep Nephritogenic strains of streptococci Nephritogenic strains of streptococci Wall protein M12 in pharyngitis, M49 in pyoderma Wall protein M12 in pharyngitis, M49 in pyoderma These strains pose ~ 15% risk of  PSGN approx 2 weeks after initial infection These strains pose ~ 15% risk of  PSGN approx 2 weeks after initial infection Antibiotic treatment to prevent GN? Antibiotic treatment to prevent GN? Simckes and Spitzer, Peds in Review, Rodriguez-Iturbe and Musser, J Am Soc Nephrology, 2008

14 The Role of Grp A Strep PANDAS = PANDAS = Post-infectious Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection Post-infectious Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection Syndenham’s Chorea and Rheumatic Fever Syndenham’s Chorea and Rheumatic Fever OCD/Tic disorders shown to emerge or worsen with temporal relation to Grp A Strep infection OCD/Tic disorders shown to emerge or worsen with temporal relation to Grp A Strep infection PANDAS patients may have higher susceptibility to Grp A Strep infection, + family h/o Rheumatic Fever PANDAS patients may have higher susceptibility to Grp A Strep infection, + family h/o Rheumatic Fever Kurlan et al. 121 (6): (2008) Pediatrics

15 Considering the DDX of PSGN Low C3 Low C % of PSGN cases have low C3 x 2 mos 80-90% of PSGN cases have low C3 x 2 mos Also seen in GN due to SLE Also seen in GN due to SLE Consider MPGN if low C3 > 2 mos Consider MPGN if low C3 > 2 mos MPGN can also present after infection MPGN can also present after infection MPGN may also  low C4 MPGN may also  low C4 Diagnose by biopsy Diagnose by biopsy TRAM-TRACKING  McCrory, Peds In Review, 1983.

16 Considering DDX of PSGN Normal C3: Normal C3: IgA Nephropathy IgA Nephropathy Suspect if recurrent hematuria with URIs/Infections Suspect if recurrent hematuria with URIs/Infections Alport’s Alport’s + Family History + Family History HUS or HSP can present with gross hematuria HUS or HSP can present with gross hematuria Post-viral GN Post-viral GN Boineau and Lewy Peds in Review 1989.

17 Treatment of AGN in General Admit if HTN, edema, or signs of renal failure Admit if HTN, edema, or signs of renal failure Monitor/correct electrolyte anomalies Monitor/correct electrolyte anomalies Treat HTN to avoid sequelae Treat HTN to avoid sequelae Diuresis  loop diuretics like lasix Diuresis  loop diuretics like lasix Fluid and salt restriction Fluid and salt restriction Anti-hypertensives like the Ca-channel blockers Anti-hypertensives like the Ca-channel blockers Simckes and Spitzer Peds in Review, 1995.

18 Treatment Specific to PSGN Antibiotics to target Grp A Strep Antibiotics to target Grp A Strep Cultures often positive even if no symptoms, suggesting active infection Cultures often positive even if no symptoms, suggesting active infection Treatment may  milder course of PSGN Treatment may  milder course of PSGN Epidemics of Grp A Strep may warrant ppx to prevent PSGN, especially in underdeveloped societies Epidemics of Grp A Strep may warrant ppx to prevent PSGN, especially in underdeveloped societies Unclear/controversial role for impact on OCD Unclear/controversial role for impact on OCD Rodriguez-Iturbe and Musser, J Am Soc Nephrology, 2008

19 Prognosis and Sequelae Good prognosis in children Good prognosis in children CLOSE follow-up! CLOSE follow-up! HTN resolves in ~ 1-2 weeks HTN resolves in ~ 1-2 weeks C3 levels return to normal in ~ 6 weeks C3 levels return to normal in ~ 6 weeks Gross hematuria resolves in ~ 6 weeks Gross hematuria resolves in ~ 6 weeks Microscopic hematuria resolves in ~ 1 year Microscopic hematuria resolves in ~ 1 year Proteinuria resolves in ~ 6 months Proteinuria resolves in ~ 6 months Progression to renal dysfunction RARE Progression to renal dysfunction RARE McCrory, Peds in Review 1983.

20 Take Home Points Urinalysis is KEY test to w/u discolored urine Urinalysis is KEY test to w/u discolored urine UA with casts/dysmorphic RBCs = GN UA with casts/dysmorphic RBCs = GN HTN, edema, or renal dysfunction  admit HTN, edema, or renal dysfunction  admit Poststrep GN = most common, due to characteristics of Strep and/or patient Poststrep GN = most common, due to characteristics of Strep and/or patient Treat Strep infection and co-morbidities Treat Strep infection and co-morbidities Guarantee follow-up Guarantee follow-up

21 Works Cited Boineau and Lewy, “Evaluation of Hematuria in Children and Adolescents,” Pediatrics in Review, Boineau and Lewy, “Evaluation of Hematuria in Children and Adolescents,” Pediatrics in Review, Kurlan et al., “Streptococcal Infections and Exacerbations of Childhood Tics and OCD Symptoms: A Prospective Blinded Cohort Study,” Pediatrics Kurlan et al., “Streptococcal Infections and Exacerbations of Childhood Tics and OCD Symptoms: A Prospective Blinded Cohort Study,” Pediatrics Massengill, “Hematuria,” Pediatrics in Review, Massengill, “Hematuria,” Pediatrics in Review, Rodriguez-Iturbe and Musser, “The Current State of Poststreptococcal Glomerulonephritis,” Journal of American Society of Nephrology, Rodriguez-Iturbe and Musser, “The Current State of Poststreptococcal Glomerulonephritis,” Journal of American Society of Nephrology, Simckes and Spitzer, “Poststreptococcal Acute Glomerulonephritis,” Pediatrics in Review, Simckes and Spitzer, “Poststreptococcal Acute Glomerulonephritis,” Pediatrics in Review, McCrory, “Glomerulonephritis,” Pediatrics in Review, McCrory, “Glomerulonephritis,” Pediatrics in Review, 1983.


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