Pediatrics Morning Report

Whats with this Back Pain?!?

Judy Vu, MD Med-Peds PGY4 December 13, 2013

History of Present Illness

S 14 y/o previously healthy white girl p/w bilateral back pain S Achy in mid back, progressed to lower back, nagging pain S Rated 5-8/10, duration ~4 days, no real exacerbating or relieving

factors
S Recalls back soreness ~1 week ago after raking a lot of leaves in

the backyard, resolved quickly and now returned

S Decreased appetite and PO intake over the same time S NBNB emesis through the night 4 nights ago S PCP evaluation the next morning (3 days prior to presentation) S CXR negative S Zofran prescribed helped until morning of presentation

HPI Continued

S Fever Tmax 101F two days ago

S Concern for dehydration brought to ED

S Other sx:
S Positive: diarrhea x1, occasional HA, face fullness according

to mom S Negative: URI sx, cough, pharyngitis, abdominal pain, dysuria, increased frequency/urgency, hematuria

Additional History
S Allergies: Decadron agitation and mood changes S Meds: PRN albuterol, PRN Zofran, PRN ibuprofen x2 for back

pain. PRN Midol or ibuprofen for menstrual cramps. Advil + Aleve in large amounts 3 months ago after ACL tear.
S PMH: No chronic illnesses, hospitalizations, or UTIs. Menstrual

cycles normal last 1 week ago. UTD on immunizations

S PSH: Tonsillectomy & adenoidectomy, thumb surgery S Fam Hx: No chronic conditions. Maternal aunt with renal stones. S Soc Hx: Lives with parents and sibs. Sister sick with URI. Attends

9th grade, enjoys school. No EtOH, tobacco, or other illicits.

Physical Exam
VS: T 37.1, HR 70, RR 14, BP 118/77, Sat 100% on RA GEN: Tired but non-toxic, lying in bed wrapped in blankets, pleasant, cooperative, NAD HEENT: NCAT, EOMI, no conjunctival injection, ears wnl, NP clear, no OP erythema or lesions, MMM/pink Neck: supple with full ROM, shotty LAD CV: RRR, nl s1 and s2, no murmur/gallop, normal pulses, CRT<3 sec PULM: CTAB with good aeration, no retractions ABD: Soft, non-distended. TTP in LLQ. No masses or HSM. Normal bowel sounds. EXT: Warm, well-perfused, no cyanosis, clubbing, edema BACK: diffusely tender to palpation lower > mid-back. No distinct CVA tenderness. SKIN: No rashes, mottling, jaundice NEURO: A&O x4, face symmetric, grossly normal strength/tone, normal reflexes.

One Liner Synopsis

14 year-old previously healthy girl with 4 days of progressive lumbar back pain, anorexia/decreased appetite, intermittent nausea, NBNB emesis, intermittent fevers

Differential Diagnosis
S

Renal S Acute renal failure S Dehydration S NSAID use S GN: RPGN, Crescentic S Tubulointerstitial: ATN, AIN S Post-obstructive S Chronic kidney disease
Infectious S UTI S Pyelonephritis S Paraspinal abscess S Osteomyelitis S POTS/TB

MSK S Muscle sprain/spasm S Rhabdomyolysis S Bruised bone S Vertebral fracture Heme/Onc S Osteosarcoma S Myosarcoma S Multiple myeloma Rheumatology/Immunology S Lupus S Ankylosing spondylitis S Juvenile Idiopathic Arthritis

Initial Evaluation
7.7 84 19 8.14 1.6 3.1

8.8

12 35

209

S Received 1 L NS S LFTs wnl, lipase 181

146 79 4.6

102

13B, 47N, 32L, 8M

S Inflammatory Markers: CRP 4.1 and ESR 47 S UA: SG >1.030, pH 5, cloudy, large Hgb, neg nitrite,

small LE, trace ketones. Micro: >30 WBC, >30 RBC, >30 epi, 3+ bacteria, >30 hyaline casts, 5 WBC casts

Additional Evaluation
S Renal Ultrasound: S Right length 11.3 cm S Left length 11.2 cm S Normal 8.8-11.9 cm for age range S No obstructive uropathy S Subtle parenchymal echogenicity in both kidneys
S Micro: + beta-hemolytic GAS
S ASO titer: 219, Dnase B: 286 S C3/C4 levels: 11 / 13 S Anti-glomerular basement

membrane Ab: negative

S MPO/PR3 Antibody: 1 / 0

S ANA: None
S ds DNA: negative S ANCA: <1:20 S CK: 112

Renal Biopsy
S Exudative glomerulonephritis

most consistent with postinfectious glomerulonephritis

S IgG and C3 staining on IF
S Subepithelial humps on EM S EM: Subepithelial humps

easily identified, rare mesangial deposit. Segmental effacement of podocyte foot processes. No crescents.

Patients Clinical Course

S Patient continued to have symptomatic uremia,

hyperkalemia, hyperphosphatemia

S Intermittent hemodialysis started on hospital day #3 x 1

week S BUN 44, Cr 1.63 after 11 days of hospitalization

S Fluid restriction 2.5 L, renal diet (LOW Na, K, Phos)

S Pulse Solu-Medrol PO prednisone

S Hypertensive amlodipine started at time of discharge S PRN Lasix for edema or weight gain >2 pounds S NO NSAIDs!!!

Complication of - hemolytic GAS

Nonsuppurative
S

Suppurative
S S S

PANDAS

AOM, PNA, sinusitis Cervical lymphadenitis Peritonsillar or retropharyngeal abscess Bacteremia, toxic shock Endocarditis Fasciitis/myositis Meningitis

S Poststreptococcal

glomerulonephritis
S

Poststreptococcal reactive arthritis Rheumatic fever

S S S S

Sydenhams chorea & other autoimmune movement disorders

Complication of - hemolytic GAS

S Complication arise predominantly from pharyngitis and

scarlet fever
S Abx reduce severity of acute sx & shorten illness by 1 day
S >90% of treated & untreated pts with acute pharyngitis are

symptom-free by day #7 of illness

S Primary reason for treating uncomplicated strep

pharyngitis?
S Reduce incidence of subsequent rheumatic fever S Reduce recurrence rate of infection S Unclear if abx tx reduces risk of APSGN

Acute Poststreptococcal GN (APSGN)

S Leading cause of acute nephritic syndrome

S Sporadic
S Most frequent in ages 2-6 S Recent hx of pharyngitis in winter months S Rash + poor personal hygiene in warmer climate

S Occurs 10 days after pharyngitis OR 2 weeks after skin

infxn
S Nephritogenic strain of GAS S Immunity is type-specific & long-lasting! Repeat infections

Clinical Presentation: APSGN

S Full-blown nephritic syndrome + oliguric acute renal failure S Complaints S PAINLESS gross hematuria (cola-colored, smoky, tea or dark red

urine) S Headache or visual disturbance, AMS S Generalized sx: anorexia, nausea, vomiting, malaise/fatigue, SOB S Flank or back pain due to swelling of renal capsule
S Exam S Hypervolemia, edema, hypertension S Coexisting rheumatic fever VERY UNUSUAL S MOST cases MILD. Subclinical cases common.

Diagnosis: APSGN
S Dx based on clinical hx and serologies! S No need for biopsy especially in children with typical hx S Urinalysis and RFP S RBC casts, proteinuria, WBC may be misdiagnosed as UTI!!!
S

Abnormalities may persist up to 6-12 months

S Mild hypoalbuminemia, if any

S Signs of inflammation S CBC

S

Leukocytosis with neutrophilia S Mild normochromic normocytic anemia (dilutional) S

ESR & CRP

S

Elevated early S Effective for monitoring disease if either returns to normal after stopping treatment, the attack is usually over

Diagnosis: APSGN
S Evidence of preceding streptococcal infection based on

serologies
S Antistreptolysin O titer (ASO)
S
S

ASO peaks at ~4-5 wks, first noted during 2nd or 3rd wk of acute episode
Peak titer at time of onset TRUE infxn rather than transient carrier!

S Antideoxyribonuclease B (DNase B) more specific, $$ S Throat cultures often negative by the time APSGN appears

S Complement levels
S VERY LOW C3 and minimal decrease in C4 S LOW C3 and LOW C4 Lupus S Normal complement IgA nephropathy S NO NEED to check CH50 a historical thing S Timely measurement!! Typically C3 normalizes in 6-8 weeks!!!

Course: APSGN
S Prognosis is GOOD!!! S >95% of pts recover spontaneously. Self-limited S Return to baseline renal function within 3-4 weeks w/o

long-term sequelae
S Best indicator of resolved dz: C3 back to normal S Biopsy indicated if S Delayed resolution S Severe renal failure at onset S Progressive renal failure S Systemic feature rash, arthralgias, HSM, persistent fevers

Treatment: APSGN
S Can be managed in primary care setting S Symptomatic diuretic & anti-hypertensive if necessary S Fluid restriction if edema S Renal diet depending on clinical scenario S Remember to check BPs and RFP S HTN & azotemia usually subside in 1-2 wks S Refer immediately to pediatric nephrologist S Severe HTN, >99%ile S Renal insufficiency. <2% need dialysis! S Extrarenal signs/symptoms (neuro complaints) S Full & complete recovery within 3 to 12 months

References
S Hahn RG et al. Evaluation of Poststreptococcal Illness. AAFP

2005;71:1949-54.
S Simckes AM, Spitzer A. Poststreptococcal Acute

Glomerulonephritis. Pediatrics in Review 1995;16;278

S Welch TR. An Approach to the Child with Acute

Glomerulonephritis. International Journal of Pediatrics.2012

S http://www.nlm.nih.gov/medlineplus

S http://www.niddk.nih.gov/