Post-Streptococcal Glomerulonephritis

Often our clinical role is similar to that of a detective. We carefully search a patient’s history and physical exam to discover the obscure clues that help us to provide excellent care. Is that pyoderma gangrenosum? We need to consider inflammatory bowel disease. 5 Days of fever? Hmmm… let’s look for those Kawasaki Disease clues. Sometimes, common conditions can lead to more rare ones and it takes our detective skills to put all of the clues together. Let’s review one such illness- Post-Streptococcal Glomerulonephritis:

Post-Streptococcal Glomerulonephritis: Basics

  • Post-Streptococcal Glomerulonephritis (PSGN) is a complication of Strep infections.
    • Rheumatic Heart Disease and Peritonsillar Abscesses (and don’t forget PANDAS) get more notoriety, but PSGN needs our attention too.
    • Most often Group A Strep infection, but cases have been linked to other strains of Strep (Strep zooepidemicus). [Demuynck, 2013; Marshall, 2011]
    • Often thought of being related to Strep Pharyngitis, but can also be related to impetigo or other strep skin infections (ex, abscess).
      • Has been associated with skin infection following Scabies. [Marshall, 2011]
      • Often associated with pharyngitis in colder climates and skin infection in warmer climates. [Demuynck, 2013]
  • PSGN is an immune-mediated reaction.
    • The specific M protein (emm types) serotypes of Strep pyogenes activate a pathway of complement. [Demuynck, 2013]
    • Antigens are deposited on the glomerular membrane. [Worthing, 2019]
  • Strep is more common in children than adults, but can occur in both.
    • Incidence has dropped in developed countries, but it is not extinct. [Demuynck, 2013; Marshall, 2011]
    • Now incidence rates are highest in under-developed regions and in certain populations, like Indigenous Australians. [Worthing, 2019; Marshall, 2011]
      • Exposure to overcrowding and inadequate sanitation seem to be important risk factors.
      • Poor access to healthcare is also a factor. [Worthing, 2019]

Post-Strep Glomerulonephritis: Evaluation

  • The classic presentation is a nephritic syndrome with acute renal failure. [Demuynck, 2013]
    • Urinalysis can show:
      • Dysmorphic RBCs
      • Red Cell Casts
      • Leukocytes
      • Proteinuria
    • Elevated serum creatinine levels are often seen at presentation.
  • Patients with glomerulonephritis may present in a variety of manners, but may have: [Demuynck, 2013]
  • Strep infection may not be apparent upon presentation.
    • Usually develops ~1.5 weeks after pharyngitis and ~3 weeks after skin infection.
    • Ask about recent skin and throat infections.
    • Check AntiStreptolysin O (ASO) titers.
  • Additional labs to consider:
    • Bun/Cr
    • Hemoglobin and platelet counts
    • Complement 3 (C3) level
  • Management: [Demuynck, 2013]
    • Treatment focuses primarily on symptom management.
      • Limit salt and water intake.
      • Loop Diuretics are commonly used for fluid management and blood pressure management.
    • Penicillin is often given to treat possible residual strep infection, but the strep infection is not “in the kidneys.”
    • May require renal replacement (hemodialysis) management in severe cases.
  • Outcomes:
    • Prognosis for acute PSGN is good as most cases resolve completely. [Demuynck, 2013; Marshall, 2011]
    • There is debate about long-term association with chronic renal impairment and failure. [Demuynck, 2013]

Moral of the Morsel

  • Simple things can become complex. It is important to consider what we are seeing in the ED as only a chapter in the story of the illness.
  • Periorbital edema requires some thoughtful consideration. It isn’t always allergies.
  • Don’t just ask about the throat. While PSGN is associated with pharyngitis, it can also be related to skin infections!

References

Worthing KA1, Lacey JA2, Price DJ3,4, McIntyre L1, Steer AC5, Tong SYC6,7, Davies MR1. Systematic Review of Group A Streptococcal emm Types Associated with Acute Post-Streptococcal Glomerulonephritis. Am J Trop Med Hyg. 2019 Mar 25. PMID: 30915958. [PubMed] [Read by QxMD]
Demircioglu Kılıc B1, Akbalık Kara M1, Buyukcelik M1, Balat A2. Pediatric post-streptococcal glomerulonephritis: Clinical and laboratory data. Pediatr Int. 2018 Jul;60(7):645-650. PMID: 29729114. [PubMed] [Read by QxMD]
Balasubramaniyan S, Selvamuthukumaran S, Krishnamoorthy K. Posterior Reversible Encephelopathy Syndrome in Post-Streptococcal Glomerulonephritis. J Assoc Physicians India. 2015 Jun;63(6):71-3. PMID: 26710406. [PubMed] [Read by QxMD]
Demuynck M1, Lerut E, Kuypers D, Evenepoel P, Claes K, Naesens M, Meijers B, Vanrenterghem Y, Bammens B. Post-streptococcal glomerulonephritis: not an extinct disease! Acta Clin Belg. 2013 May-Jun;68(3):215-7. PMID: 24156223. [PubMed] [Read by QxMD]
Hoy WE1, White AV2, Dowling A3, Sharma SK3, Bloomfield H3, Tipiloura BT4, Swanson CE3, Mathews JD5, McCredie DA6. Post-streptococcal glomerulonephritis is a strong risk factor for chronic kidney disease in later life. Kidney Int. 2012 May;81(10):1026-1032. PMID: 22297679. [PubMed] [Read by QxMD]
Marshall CS1, Cheng AC, Markey PG, Towers RJ, Richardson LJ, Fagan PK, Scott L, Krause VL, Currie BJ. Acute post-streptococcal glomerulonephritis in the Northern Territory of Australia: a review of 16 years data and comparison with the literature. Am J Trop Med Hyg. 2011 Oct;85(4):703-10. PMID: 21976576. [PubMed] [Read by QxMD]
Jackson SJ1, Steer AC, Campbell H. Systematic Review: Estimation of global burden of non-suppurative sequelae of upper respiratory tract infection: rheumatic fever and post-streptococcal glomerulonephritis. Trop Med Int Health. 2011 Jan;16(1):2-11. PMID: 21371205. [PubMed] [Read by QxMD]
Feldon M1, Dorfman L, Tauber T, Morad Y, Bistritzer T, Goldman M. Post-streptococcal glomerulonephritis and uveitis–a case report. Pediatr Nephrol. 2010 Nov;25(11):2351-3. PMID: 20517620. [PubMed] [Read by QxMD]
Nordstrand A1, Norgren M, Holm SE. Pathogenic mechanism of acute post-streptococcal glomerulonephritis. Scand J Infect Dis. 1999;31(6):523-37. PMID: 10680980. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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