An oedematous 15 year old

A 15 year girl presents to Queen Elizabeth Hospital Blantyre with a one-month history of facial oedema.  It is worse in the morning, slightly better at night and not associated with shortness of breath or cough.  She has been well recently, with no intercurrent illnesses.  She has never had any body swelling until noticing swelling of her feet in the last week or two. On further questioning, 6 months ago she probably had an episode of macroscopic haematuria.  She has not reached menarche.  She lives in Nkhotakota.

On examination she is slim but has marked bilateral pitting pedal oedema and facial puffiness; she probably also has ascites.  She is apyrexial.  General examination is unremarkable.  Her BP is 110/60, pulse 72.  She has reduced breath sounds and dullness to percussion at both lung bases.  Heart sounds and abdomen are normal and she has no neurological deficit.

A urine dipstick shows 4+ protein, 3+ blood.  She has a serum creatinine of 60 micromol/l (0.7 mg/dl) and a normal blood count.  Tests of liver function, serum proteins are not available.

  1. What is the differential diagnosis at this stage?
  2. Further immunological tests are not possible, nor is a renal biopsy, but what simple tests are essential to your management?

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The urine dipstick findings are strongly suggestive of ‘nephritic’ type glomerulonephritis.  In this region, post-infectious glomerulonephritis is the most likely cause, though the history here is long, and she is not hypertensive.  Other causes are certainly possible.  However …

Urine microscopy is a key test in a patient with suspected glomerulonephritis.  In her case it showed red cells, but these were of normal shape, and no casts were seen.  However Schistosoma haematobium ova were seen.

Schistosomiasis is endemic around Lake Malawi.  A positive dipstick test for blood would usually be taken to indicate current infection.  Serology for Schistosoma antibodies is of no value as previous exposure is usual.

This complicates interpretation and management significantly.  Given that her creatinine and blood pressure were normal, she was treated for Schistosomiasis and reviewed one month later.  At that review she is still oedematous and urine dipstick shows 4+ protein.  Now what do you think?

Read more in A 16 year old girl with oedema

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Case contributed by Fran Th’ng and Gavin Dreyer


 

 

 

Persistent Microscopic Haematuria (4)

An 81 year old lady has persistent microscopic haematuria and negative MSUs.  She is also on warfarin (last INR 3.4) for AF and has hypertension (last BP 162/80).

She has a history of cutaneous vasculitis and was seen by dermatology regarding a lesion on her leg a few years ago, but this all seemed to settle.  Urology investigated the same problem of microscopic haematuria 2 years ago and all investigations were normal.

Her ESR is slightly up at 28, but I wonder if the most likely cause is her raised BP and possibly warfarin use, but I would be grateful for your advice as to whether I should be doing anything else or you would wish to see her?

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Results of investigations are as follows;
Blood – ESR  28 / CRP – 2 / eGFR 51  (stable compared to previous results)

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Given your history and normal urological investigations, I would be tempted to just carry on doing what you’re doing, albeit with some further BP control.

It seems unlikely that after this long without progression, her haematuria is caused by systemic vasculitis, but an ANCA would be informative if positive.

However the golden rule is that with normal urological investigations, normal renal function (eGFR of 51 if stable will do at 81), no proteinuria and normotensive, then microscopic haematuria can simply be observed. I would monitor these variables – infrequently – and see what happens. We can always review the situation if things are changing but I think she’ll just remain stable.


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