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- Alexandra Charron, MD*
- Laura Hesemann, MD†
- Joseph P. Gaut, MD, PhD‡
- T. Keefe Davis, MD†
- *Pediatrics, Saint Louis Children’s Hospital, St Louis, MO
- †Division of Pediatric Nephrology and
- ‡Division of Anatomic and Molecular Pathology, Washington University School of Medicine, St Louis, MO
AUTHOR DISCLOSURE
Drs Charron, Hesemann, Gaut, and Davis have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Presentation
A previously healthy 14-year-old girl presents with 2 weeks of malaise and abnormal laboratory results. She presented to her pediatrician 1 week ago with fever and fatigue and received amoxicillin for culture-positive streptococcal pharyngitis. However, she had no improvement and began having daily episodes of nonbloody, nonbilious emesis. One day ago she noted decreased urine output, facial puffiness, and mild abdominal distention. Currently, she reports no headaches, epistaxis, sinusitis, or respiratory symptoms.
On physical examination, she is afebrile, with a heart rate of 78 beats/min and blood pressure of 149/85 mm Hg. She appears well, with normal physical findings except mild facial and lower extremity edema and mild abdominal distention.
Initial laboratory results are:
Sodium 125 mEq/L (125 mmol/L)
Potassium 8.5 mEq/L (8.5 mmol/L)
Chloride 91 mEq/L (91 mmol/L)
Bicarbonate 14 mEq/L (14 mmol/L)
Blood urea nitrogen 167 mg/dL (59.62 mmol/L)
Creatinine 24.2 mg/dL (2,139.28 μmol/L)
White blood cell count 13,400/μL (13.4 × 109/L)
Hemoglobin 8.9 g/dL (89 g/L)
Electrocardiography reveals normal sinus rhythm without peaked T waves. Kidney ultrasonography shows enlarged, slightly echogenic kidneys.
Discussion
Differential Diagnosis
The constellation of symptoms and initial laboratory findings were concerning for glomerulonephritis (GN). Acute GN has a broad differential diagnosis, with acute poststreptococcal GN occurring most commonly in children. Other possibilities include immune complex–mediated GN, including immunoglobulin (Ig)A nephropathy and lupus nephritis, as well as pauci-immune forms of rapidly progressive GN (RPGN), such as granulomatosis with …
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