centered image

centered image

26-year old man with bilateral leg edema.

Discussion in 'Case Studies' started by J.P.C. Peper, Aug 17, 2012.

  1. J.P.C. Peper

    J.P.C. Peper Bronze Member

    Joined:
    Apr 8, 2012
    Messages:
    875
    Likes Received:
    60
    Trophy Points:
    1,245
    Gender:
    Male
    Occupation:
    Medical student (since 2009)
    Practicing medicine in:
    Netherlands

    A 26-year old man visits his doctor because of bilateral leg edema. A couple of months earlier, he also suffered from pain in his flanks. The pain started after an episode of flu-like symptoms and a sore throat. He also passed dark brown urine back then, but only for a few days. Several days after that, all his complaints had disappeared. He had no skin problems, joint pain or abdominal pain.

    Lab results reveal a plasma creatinine of 175 micromol/l and proteinuria (3”“5 g/24h). The urine contains erythrocytes, as well. His blood pressure is 160/100 mm Hg. The throat culture is negative and AST-levels are normal. Plasma complement factor is also normal.

    Questions.

    1. What’s your differential diagnosis?

    2. What investigations should be done?
     

    Add Reply

  2. J.P.C. Peper

    J.P.C. Peper Bronze Member

    Joined:
    Apr 8, 2012
    Messages:
    875
    Likes Received:
    60
    Trophy Points:
    1,245
    Gender:
    Male
    Occupation:
    Medical student (since 2009)
    Practicing medicine in:
    Netherlands
    If anyone has an idea, there's still time.

    I'll post the correct answer in another week.
     

  3. shobitha

    shobitha Active member

    Joined:
    Aug 20, 2012
    Messages:
    29
    Likes Received:
    1
    Trophy Points:
    40
    Occupation:
    doctor
    Practicing medicine in:
    Sri Lanka
    DD
    1.acute glomerulonephritis (post streptococcal) - , hypertension, propeinuria & ankledema are suggestive features in this case. and, AGN occured several weeks after sorethroat.

    2.IgA nephropathy - this occurs within a day or two of URTI. haematuria is frank & episodic, and proteinuria can be there.
    A
     

    Adriana GALVIS likes this.
  4. J.P.C. Peper

    J.P.C. Peper Bronze Member

    Joined:
    Apr 8, 2012
    Messages:
    875
    Likes Received:
    60
    Trophy Points:
    1,245
    Gender:
    Male
    Occupation:
    Medical student (since 2009)
    Practicing medicine in:
    Netherlands
    Answers.

    1.

    A history of haematuria and flank pain, shortly after a viral upper respiratory tract infection is a classic presentation of IgA-glomerulonephritis. The symptoms usually last for a few days and can re-emerge in a period of the flu. Between these periods, there’s usually microscopic erythrocyturia. Although the patient is often worried, the haematuria on itself doesn’t mean there’s a bad prognosis.

    Also consider acute post-streptococcus glomerulonephritis. It’s less likely however, because in this condition there’s usually a latency period of about ten days between the infection and the glomerulonephritis.

    A possible third option could be Henoch-Schönlein disease, as this can also present with haematuria. However, purpura is common in this disease and this patient didn’t have skin problems.

    2.

    Plasma IgA-levels can be elevated in IgA-glomerulonephritis. IgA-immune complexes can also be found in the circulation. Thirdly, a biopsy of (healthy) skin may show IgA depositions in the blood vessel walls. A kidney biopsy could be conclusive, although microscopic findings may mimic Henoch-Schönlein disease.

    Literature.

    ’Klinische nefrologie’ (De Jong et al.) (4th edition); a Dutch medical book on nephrology.
     

  5. anshu

    anshu Active member

    Joined:
    Jun 6, 2013
    Messages:
    68
    Likes Received:
    2
    Trophy Points:
    90
    Gender:
    Female
    Practicing medicine in:
    India
    umm..
    dont we consider venous insufficiency and thyroid disorders in such cases?what abot pelvic mass or some ...compression in the lower abdo..

    i know of a case not the same though an oldish guy,b/l pedla edema,more profound in evening,h/o of sorethroat some few weeks back,mildly raised creatinine,rest all investigations normal,except a raised uric acid there,and a k/c/o-BPH..
    what do u think could be his reason for b/l pedal edema?..

    would appreciate a short explantion..thanks!
     

  6. J.P.C. Peper

    J.P.C. Peper Bronze Member

    Joined:
    Apr 8, 2012
    Messages:
    875
    Likes Received:
    60
    Trophy Points:
    1,245
    Gender:
    Male
    Occupation:
    Medical student (since 2009)
    Practicing medicine in:
    Netherlands
    Venous insufficiency is unlikely in the absence of skin symptoms, and it usually doesn’t present in both legs at the same time. An abdominal mass in a young man presenting with leg edema (and no abdominal pain) isn’t high in my DDx either, especially because this is a classic presentation of a renal disease.

    I think your case is actually quite similar to this one (especially because he may also have had a viral URTI), so in my opinion the edema could be explained by renal insufficiency. Elevated uric acid in the serum could be explained by reduced excretion because of the insufficiency. But since he’s old heart failure can also be present, of course (but that alone wouldn’t explain all of the symptoms).
     

    Adriana GALVIS and anshu like this.
  7. anshu

    anshu Active member

    Joined:
    Jun 6, 2013
    Messages:
    68
    Likes Received:
    2
    Trophy Points:
    90
    Gender:
    Female
    Practicing medicine in:
    India
    thankyou so much dr.peper,
    umm..what if the urine examination is normal in such a case..do we still consider it as GN?or do we wait and redo the whole urine routine and microscopy and 24hr urinary protein..

    in case it is GN-what treatment should be recomended at the anvil..considering he is a hypertensive with no heart failure with raised uric acid and BPH..

    kindly do give an answer, i'd be grateful.
     

  8. ishu90

    ishu90 Young Member

    Joined:
    Jul 3, 2013
    Messages:
    8
    Likes Received:
    0
    Trophy Points:
    20
    Practicing medicine in:
    India
    post streptococcal glomerulonephritis could be a possibility but its more common after a skin infection as compared to a throat infection and may hv a fever, however v may consider it as a differential diagnosis. its self resolving suggests a sort of an infectious pathology but normal complements and absent antigens.he has proteinuria and hematuria and hypertension suggestive of surely a form of nephritis....differential diagnosis could be 1.psgn 2.goodpasture syndrome(would hv had hemoptysis before nephritis) 3.history in not illustrative maybe he had drug induced nephritis which resolved on stopping the drug.
    Investigations to carry out are monitoring proteinuria and hematuria with ASO Titres,c3 complement, if need be a renal biopsy with fluorescent microscopy.
     

  9. Luis

    Luis Active member

    Joined:
    Jul 21, 2013
    Messages:
    5
    Likes Received:
    2
    Trophy Points:
    25
    Gender:
    Male
    Practicing medicine in:
    Panama
    For me it is also a post streptococcal glomerulonephritis, according to the patient´s past medical history and to what was found on the physical exam. The interesting part of this story is that he had bilateral leg edema, now when we have a patient like that we should think on the 3 major causes that can lead to this wich are (differential diagnosis):
    - heart disease (heart failure)
    - liver disease ( hypoproteinemia- liver failure)
    - renal disease (like the one we have on this case report)
    we can also rule out entities that lead to a unilateral led edema like:
    - venous insufficiency
    -lymphangitis

    About the studies that should be done we have:
    - complete blood count
    - ASO tire
    - creatinin
    - c3 and c5 complement
    - renal biospy
     

    dr NMS and dilki punchihewa like this.
  10. muhammad ehtisham

    muhammad ehtisham Young Member

    Joined:
    Dec 3, 2013
    Messages:
    2
    Likes Received:
    0
    Trophy Points:
    5
    Gender:
    Male
    Practicing medicine in:
    Pakistan
     

  11. setar

    setar Young Member

    Joined:
    Dec 2, 2013
    Messages:
    2
    Likes Received:
    1
    Trophy Points:
    5
    Gender:
    Male
    Practicing medicine in:
    Iran
    Ig A nephropathy
     

    medico likes this.
  12. dr_allahnoori

    dr_allahnoori Active member

    Joined:
    Dec 26, 2013
    Messages:
    33
    Likes Received:
    0
    Trophy Points:
    40
    Gender:
    Male
    Practicing medicine in:
    Iran
     

  13. Dr Geofrey L. Mdede

    Dr Geofrey L. Mdede Well-Known Member

    Joined:
    Jan 23, 2014
    Messages:
    17
    Likes Received:
    4
    Trophy Points:
    235
    Gender:
    Male
    Practicing medicine in:
    Tanzania
    Nephrotic syndrome
    renal Ct scan, renal biopsy,
     

  14. medico

    medico Young Member

    Joined:
    Jan 25, 2014
    Messages:
    5
    Likes Received:
    0
    Trophy Points:
    20
    Gender:
    Male
    Practicing medicine in:
    Mexico
     

  15. medico

    medico Young Member

    Joined:
    Jan 25, 2014
    Messages:
    5
    Likes Received:
    0
    Trophy Points:
    20
    Gender:
    Male
    Practicing medicine in:
    Mexico
    El paciente presenta una glomerulonefritis aguda post estreptocica.
     

  16. Dr Yarzar Tun

    Dr Yarzar Tun Young Member

    Joined:
    Jan 28, 2014
    Messages:
    1
    Likes Received:
    0
    Trophy Points:
    5
    Gender:
    Male
    Practicing medicine in:
    Myanmar
    Acute Post Streptococcal Glomerulonephritis
     

  17. The Physician

    The Physician Active member

    Joined:
    Jan 28, 2014
    Messages:
    13
    Likes Received:
    0
    Trophy Points:
    25
    Gender:
    Male
    Occupation:
    medical student
    Location:
    Cape Town, Western Cape
    Practicing medicine in:
    South Africa
    A streptolysin O titre(ASOT)
    Serum cholesterol
    Full blood count
    Electrolytes
    Urine microscopy
     

    Last edited: Jan 28, 2014
  18. The Physician

    The Physician Active member

    Joined:
    Jan 28, 2014
    Messages:
    13
    Likes Received:
    0
    Trophy Points:
    25
    Gender:
    Male
    Occupation:
    medical student
    Location:
    Cape Town, Western Cape
    Practicing medicine in:
    South Africa
     

  19. brunette

    brunette Well-Known Member

    Joined:
    Feb 2, 2014
    Messages:
    19
    Likes Received:
    1
    Trophy Points:
    230
    Gender:
    Female
    Location:
    Nanchang, Jiangxi
    Practicing medicine in:
    China
     

  20. brunette

    brunette Well-Known Member

    Joined:
    Feb 2, 2014
    Messages:
    19
    Likes Received:
    1
    Trophy Points:
    230
    Gender:
    Female
    Location:
    Nanchang, Jiangxi
    Practicing medicine in:
    China
    rapidly progressive glomerulonephritis
    immunological test GMB,ANC,complement ,c3,ASO
     

Share This Page

<