26-year old man with bilateral leg edema.

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?

 

If anyone has an idea, there's still time.

I'll post the correct answer in another week.

 

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

 

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.

 

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!

 

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).

 

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.

 

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.

 

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

 

Ig A nephropathy

 

Nephrotic syndrome
renal Ct scan, renal biopsy,

 

El paciente presenta una glomerulonefritis aguda post estreptocica.

 

Acute Post Streptococcal Glomerulonephritis

 

A streptolysin O titre(ASOT)
Serum cholesterol
Full blood count
Electrolytes
Urine microscopy

 

rapidly progressive glomerulonephritis
immunological test GMB,ANC,complement ,c3,ASO