MORNING REPORT

Brittany Esty 11/26/12

HPI
6 year old previously healthy male presenting with 4 week history of bloody urine. Symptoms began about 4 weeks ago when parents noted a hint of red when he urinated in the toilet. This then changed to brownish in color and then returned to normal. One week ago his urine was light and in color but still was slightly red. He was had a runny nose a about 4.5 weeks ago He has had headaches on and off during this time.

HPI Continued

He denies any dysuria, suprapubic pain or flank pain. He does describe some daytime urgency and nocturnal enuresis He has had no concurrent fever, cough, sore throat, vomiting or diarrhea. Denies abdominal pain, rash or joint pain Denies swelling No history of trauma ROS: otherwise negative

Additional History

PMH

Uncomplicated pregnancy. C-section delivery at 40 weeks gestation with a birth weight of 7 lbs. 10 oz. Primary nocturnal enuresis over past year. Constipation on and off since infancy. Treatment with MiraLax in the past and fiber containing foods currently.

ALLERGIES:No known drug allergies. MEDICATIONS:Multivitamin daily IMMUNIZATIONS:Up-to-date. FAMILY HISTORY:Maternal grandmother with hypertension and type 2 diabetes SOCIAL HISTORY: Parents are divorced. The patient lives with his mother. He has one older sibling. He is currently in the 1st grade at Challenger school.

Physical Exam

VITAL SIGNS: Weight: 22.70 Kgs (Weight Percentile: 48), Height: 114.20 cm (Height Percentile: 9), Temperature: 36.7, Blood pressure 95/50, HR: 84/min, RR: 26/min GENERAL: Awake, alert and cooperative. NAD HEAD: Normocephalic and atraumatic. EYES: PERRLA. EOMI. No periorbital edema. Conjunctiva and sclera normal. EARS: Tympanic membranes and ear canals normal. OROPHARYNX: Clear. Dentition normal. Tonsils symmetric and without exudate. NECK: Supple without mass. No thyromegaly. LYMPH NODES: No cervical, submandibular, inguinal adenopathy. RESP: Clear bilaterally. No adventiuous sounds. No increased WOB

Physical Exam

CVS: Regular rate and rhythm. 2/6 vibratory systolic ejection murmur heard best at the lateral sternal border. PMI normal. Pulses 2+ in all 4 extremities. ABDOMEN: Active bowel sounds. Soft, nontender nondistended. No hepatosplenomegaly or masses. BACK: No CVA tenderness. EXTREMITIES: Small amount pitting edema up to midcalf. Joints normal with no erythema, swelling reduced range of motion. No deformities. GU: Tanner one male. Circumcised. Testes descended. No scrotal edema. Normal urethral opening NEURO: Awake and alert. Symmetric cranial nerves. Tone and strength symmetric. Gait normal. SKIN: No rash or lesions. Dry skin.

Differential diagnosis

Renal

ID

Glomerulonephritis
n n n n n n

Minimal change disease FSGN Membranous IgA nephropathy Post infectious acute GN Rapidly progressive (cresentic)

Urinary tract infection Adenovirus (hemorrhagic cystitis) TB (associated renal disease) HIV ESLD Biliary atresia Celiac disease Meatal stenosis Idiopathic urethrorrhagia Trauma Rhabdomyolysis Drugs
n n

GI

Nephrolitiasis AD polycystic kidney Alports Renal mass/tumor SLE Wegners HSP Coagulopathy Sickle cell disease TTP/HUS Tumor

Urologic

Rheum

Other

Heme/Onc

Sulfonamides Nitrofurantion Lead

Toxins
n

LABS, urine
POC Urine: gravity 1.015, large hem and 2+ protein on dipstick. Microscopic examination revealed >30 red blood cells per high-powered field and 10-15 white blood cells per high-powered field. granular casts and some red blood cell casts Urine protein and creatinine ratio 17.2 Urine culture no growth

LABS
Sodium 137, potassium 4.7, CO2 25, glucose 75, BUN 21, creatinine 0.64, albumin 2.6, calcium 8.3, phosphorus 6.4 WBC 9.6, Hgb 10.5, HCT 30.1, MCV 82.5, platelets 327. ESR 64 ASO less than 50 C3: 121 C4: 27

LABS
Cholesterol 314, triglycerides 479, HDL cholesterol 35. LDL normal. ANA and dsDNA: negative. Antineutrophil cytoplasmic antibody panel: negative

IMAGING

Renal ultrasound:

showed mild bilateral urothelial thickening, bladder wall thickening and mild dilation of distal ureters suggesting possible infection or reflux. Kidneys had normal size and echogenicity.

Biopsy results

IgA nephropathy

IgA nephropathy

IgA nephropathy is the most common glomerulonephritis throughout the world Primary IgA nephropathy is characterized by deposition of the IgA antibiotdy in the glomerulus The suspicion of a diagnosis of IgA nephropathy is generally based upon the clinical history and laboratory data. The diagnosis can be confirmed onlyby kidney biopsy with immunofluorescence or immunoperoxidase studies for IgA deposits. (IgA depositis must be greater than IgG)

IgA nephropathy
Classic presentation, like this case, is episodic frank hematuria Typically starts a couple days following a non specific upper respiratory tract infection (less commonly following gastrointestinal or urinary tract infection) leading to IgA antibody production Other diseases associated with glomerular IgA deposits

HSP,

which is indistinguishable based off kidney biopsy from IgA nephrophathy (difference lie in presentation)

Review: Normal Glomerulus

Review: Normal Glomerulus

IgA nephropathy

Questions

References
Massengill, SF. Hematuria. Pediatrics in Review. 2008;29; 342. Webpath: http://library.med.utah.edu/WebPath/ RENAHTML/RENALIDX.html#10 Uptodate