Post-Streptococcal Glomerulonephritis in Children: Clinical Case

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Clinical Case of Post-Streptococcal Glomerulonephritis in Children

Clinical Case: Post-Streptococcal Glomerulonephritis in a 7-year-old Boy

A 7-year-old boy, John, is brought to the pediatric clinic by his mother with complaints of facial puffiness, decreased urine output, and tea-colored urine for the past two days. His mother mentions that John had a sore throat and fever about two weeks ago, which resolved on its own.

History:

  • No significant past medical history
  • No known allergies
  • Immunizations up to date
  • No family history of kidney disease

Physical Examination:

  • Temperature: 37.8°C
  • Blood Pressure: 130/85 mmHg (>95th percentile for age and height)
  • Heart Rate: 100 beats/min
  • Respiratory Rate: 22 breaths/min
  • Weight: 26 kg (2 kg increase from last recorded weight 3 months ago)
  • Periorbital and facial edema noted
  • Mild pedal edema present
  • Lungs clear to auscultation
  • Heart sounds normal, no murmurs
  • Abdomen soft, non-tender, no organomegaly

Laboratory Findings:

  • Urinalysis:
    • Color: Tea-colored
    • Protein: 3+
    • Blood: 3+
    • RBC: >50/hpf
    • WBC: 5-10/hpf
  • Serum creatinine: 1.2 mg/dL (elevated for age)
  • BUN: 30 mg/dL
  • Serum C3 complement: 40 mg/dL (low, normal range 90-180 mg/dL)
  • ASO titer: 800 IU/mL (elevated, normal <200 IU/mL)
  • Anti-DNase B: 680 U/mL (elevated, normal <170 U/mL)
  • Throat culture: Negative for Group A Streptococcus

Diagnosis:

Based on the clinical presentation, recent history of sore throat, laboratory findings (especially low C3 complement and elevated ASO titer), and urinalysis results, a diagnosis of Post-Streptococcal Glomerulonephritis (PSGN) is made.

Management:

  1. Admission for close monitoring and management
  2. Fluid and sodium restriction
  3. Blood pressure control with a calcium channel blocker (Amlodipine)
  4. Furosemide for edema management
  5. Penicillin V to eradicate any remaining streptococcal infection
  6. Daily weight, input/output monitoring
  7. Serial blood pressure measurements
  8. Follow-up urinalysis and serum creatinine

Outcome:

John's condition improves over the next 5 days. His edema resolves, urine output normalizes, and blood pressure returns to normal range. He is discharged with follow-up appointments to monitor for complete resolution of symptoms and normalization of laboratory values.



Clinical Presentations of Post-Streptococcal Glomerulonephritis in Children

Five Different Clinical Presentations of PSGN in Children

  1. Classic Nephritic Syndrome

    • Sudden onset of cola-colored or tea-colored urine
    • Periorbital and facial edema, often noticed first thing in the morning
    • Oliguria (decreased urine output)
    • Hypertension
    • Mild to moderate peripheral edema
    • History of recent streptococcal infection (usually 1-3 weeks prior)

  2. Hypertensive Emergency

    • Severe hypertension (often >99th percentile for age, sex, and height)
    • Headache, visual disturbances, or altered mental status
    • Seizures in extreme cases
    • Posterior reversible encephalopathy syndrome (PRES) may occur
    • Other features of PSGN may be present but overshadowed by hypertensive symptoms

  3. Rapidly Progressive Glomerulonephritis (RPGN)

    • Rapid decline in renal function over days to weeks
    • Severe oliguria or anuria
    • Uremic symptoms: nausea, vomiting, lethargy
    • Severe edema and hypertension
    • May require dialysis
    • More common in older children or adolescents

  4. Subclinical or Asymptomatic Presentation

    • Discovered incidentally during urine screening or family member screening
    • Microscopic hematuria with or without proteinuria
    • No visible edema or hypertension
    • Patient may be unaware of recent streptococcal infection
    • Normal renal function

  5. Nephrotic-Nephritic Overlap

    • Features of both nephritic and nephrotic syndrome
    • Significant proteinuria (>40 mg/m²/hour or urine protein/creatinine ratio >2)
    • Hypoalbuminemia (<2.5 g/dL)
    • Severe edema, including possible ascites or pleural effusions
    • Hematuria and hypertension typical of nephritic syndrome
    • May have more severe and prolonged course


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