Presentation on theme: "Orange Urine on Halloween"— Presentation transcript:
1 Orange Urine on Halloween Eva Delgado, MDMorning Report
2 Overview Case Presentation Indications for Referral/Admission Work-up based on DifferentialDiscussion of PathophysiologyTreatment and PrognosisTake Home Points
3 Case 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.
4 Case 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
5 A 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
6 A 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.
7 Physical 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
8 Differential 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
9 Thinking 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.
10 Glomerulopathy 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.
12 Poststreptococcal 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.
13 The 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
14 The 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
15 Considering 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.
16 Considering 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.
17 Treatment 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.
18 Treatment 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
19 Prognosis 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.
20 Take 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
21 Works 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.