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2. 14 year old Saudi young female student
C/0 fever- Headache for 10 days
General malaise
Dark urine x 3 days
3. HPI Fever intermittent
Muscular joint pain
no skin rash
urine character
edema
4. PH & Med
antibiotic & NSAID
Social Hx
S. review
FH
5. Examination Bp : 160/90 &Pulse 120/MIN
Temp 39 C Resp 25/MIN .pale
Look Sick
Puffiness in face
Head& neck
JVP high
6. Chest: Bronchial breathing
decrease Breath Rt side
Increase TVF
Increase Dull percussion
S1 increase
S2 N
S3 Positive
pan systolic murmur
radiation to axilla
grade 3
7. Abd
tend epigastic
tend lions
BS + ve
CNS
Drawsy
M.S
tender joint &muscle
8. Initial Diagnosis Fever? Infection
RT lung consolidation
M R
HEAMATURIA:
Renal stone
(ARF AKI- ATN)
Acute glomerulonephritis (post infection)
GN
RPGN
IgA
Hemolytic anemia
hemolytic uremic syndrome
NSAID
papillary necrosis
9.
Investigation
WBC 15000 cells per microliter
Hb 100 g/L
Plat 150 g/L
PT normal
PPT normal Sec
Bl film Sec
10. U & E
Scr 210 mml
urea 20 mmol/L
K6 mmol/L
Na 125 mmol/L
Ca 1.9 mmol/L
album 28 g/L
11. Urine Analysis few RBC
No cast
Protein 1.2g/24h
12. U/S : kid size ENLARGE 12.2CM
15. Treatment Patient receive ceftrixone IV and IV fluid
TREAT HYPERKALEMIA
17. Management:
IV lasix
Repeat urine analysis
RBC CAST
ANCA(P) positive
Kidney Biopsy
RPGN
Final diagnosis microscopic polyangitis
19. Glomerular Disease Acute Glomerulonephritis Post infectious glomerulonephritis
Group A Strep Infection
Infective endcarditis
Membranoproliferative glomerulonephritis:
Systemic lupus erythematosus
Hepatitis C virus Rapidly progressive glomerulonephritis Vasculitis (cryoglobulinemia
Type I RPGN (direct antibody)
Good Posture syndrome
Type II RPGN (immune complex)
Post infectious
Systematic lupus erythematosus
Henoch Schonlein pupura (IgA)
Others
Type III RPGN (pauci-immune)
Wegener granulomatosis
Microscopic polyarteritis
20. Investigations for Glomerulonephritis Regular Follow-up and U&E
Antistreptolysin O (ASO)
ANA, Anti DNA
C3-C4
ANCA (p, c)
HCV Antibody HBsAg
HIV
RF
Cryoglobulin
Anti-basement Membrane Antibody (With lung hemorrhage)
21. Acute postinfection Glomerulonephritis Often associated with group A
B-hemolytic streptococcal type 12 infection
Abrupt onset 10-12 days after strept throat or 14-21 skin infection (impetigo)
Also staphylococcus or viruses
22. Acute Glomerulonephritis Symptoms occur 10-21 days after infection
Hematuria
Proteinuria
Decreased GFR, oliguria
Hypertension
Edema around eyes, feet and ankles
Ascites or pleural effusion
Low C3, normal C4, Antistreptolysin O (ASO)
Kidney biopsy immune complexes and proliferation,
23. Proliferative GN- poststretococcal
24. Poststreptococcal GN
26. Post-Streptococcal Glomerulonephritis CONSERATIVE TREATMENT (acute kidney injury)
Improves 1-4 weeks, C3 normalizes in 1-3 months, hypertension improves 1-3 months, intermittent hematuria x 3 years
99% complete recovery in children and 85% in adult
27. IgA Nephropathy (Berger's Disease)
Most common acute glomerulonephritis in US ;South East Asia
Associated with H.S. Purpura
Upper respiratory(50%) IN 12 Day(Synpharyngitic hematuria)
Primary versus secondary (IBD, Liver Disease, SLE, vasculitis)
50% risk of CRF
Proteinuria, hypertension, renal insufficiency predict worse prognosis
50% increased IgA, normal compliments
TREATEMENT COSERVATIVE; ACEI
HIGH RISK: patient prednisone & alkylating agent
(cyclophosphamide-azothroprim) &ASA&ACEI&tosilectomy
28. Rapidly Progressive GN
Develops over a period of days or weeks
Primarily adults in 50s and 60s
Progresses to renal failure in a few weeks or months
Hematuria is common, may see proteinuria, edema or hypertension
29. Rapidly Progressive (Crescentic) Glomerulonephritis
33. MICROSCOPIC POLYANGITIS Necrotizing vasculitis of small- and medium- sized vessels in both the arterial and venous circulations
Frequently involves the lung and the kidneys with typical complications of hemorrhage and glomerulonephritis
Associated with ANCA in three-fourths of all cases, usually anti-myeloperoxidase antibodies (MPO-ANCA) that cause a P-ANCA pattern on immuno-flourescence testing. ANCA directedf againsts proteinae-3 (PR3-ANCA) can also be observed in microscopic polyangiitis
38. Treatment Initial Therapy
Combination cyclophosphamide-corticosteroid therapy
A slow steroid taper, with the goal of reaching 20 mg of prednisone per day by the end of two months and an overall glucocorticoid course of between 6 and 9 months.
Either daily oral or monthly intravenous cyclophosphamide.
39. Treatment Plasmapheresis
Severe manifestations of pulmonary hemorrhage on presentation.
Dialysis-dependent renal failure upon presentation.
Concurrent anti-GBM antibodies.
40. Goodpasture Syndrome Antibody formation against pulmonary and glomerular capillary basement membranes
Damage glomerular basement membrane
Men 20 - 30 years of age
Pulmonary hemorrhage and renal failure
TREATMENT:
Early treatment is essential
Pulse Steroid (10 mg/ kg/day for 3-5 days)
Cyclophosphamide
Plasmaphorisis
41. Goodpastures syndrome