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Clinical Case Analysis
Patient: 19-year-old male student
Key history: 2 days of illness; 3 weeks ago had acute purulent tonsillitis (ARVI in childhood); urine color changed to reddish-brown, then swelling and headache developed
Exam: Face swollen, moderate severity, pale skin; pharynx hyperemic, tonsils not enlarged; BP 170/100 mmHg; HR 94/min; abdomen soft, painless; kidneys not palpable; submandibular lymph nodes not enlarged
Question 1: Main Symptoms and Syndromes
Symptoms:
| Symptom | Significance |
|---|---|
| Reddish-brown (cola-colored) urine | Macroscopic hematuria |
| Decreased daily urine output (oliguria) | Impaired renal filtration |
| Facial and limb edema | Fluid retention / nephritic edema |
| Headache | Hypertensive symptom |
| BP 170/100 mmHg | Hypertension |
| HR 94/min | Mild tachycardia (compensatory) |
| Preceding purulent tonsillitis 3 weeks prior | Streptococcal trigger |
Syndromes:
1. Nephritic Syndrome (the dominant syndrome)
- Hematuria (reddish-brown urine)
- Edema (face and limbs — nephritic, non-pitting/dependent distribution)
- Hypertension (BP 170/100)
- Oliguria
2. Hypertensive Syndrome
- Elevated BP 170/100 mmHg
- Headache
- Resulting from sodium/water retention due to glomerular inflammation
3. Urinary Syndrome
- Gross hematuria (cola/reddish-brown urine)
- Oliguria (decreased daily urination)
Likely Diagnosis: Post-Streptococcal Glomerulonephritis (PSGN)
The classic latent period of 2–4 weeks between streptococcal throat infection and nephritis is perfectly matched here (purulent tonsillitis 3 weeks ago → nephritis now). PSGN is an immune complex–mediated glomerulonephritis caused by Group A Streptococcus, presenting as nephritic syndrome with hematuria, edema, hypertension, and oliguria. — Goldman-Cecil Medicine
Question 2: Survey (Investigation) Plan
Urinalysis
- General urinalysis: confirm hematuria (RBCs), proteinuria (usually mild, <3.5 g/day in nephritic), cylindruria (RBC casts — pathognomonic), specific gravity
- Zimnitsky test (urine concentration test): assess kidney concentrating function
- Daily proteinuria (24-hour urine)
- Nechiporenko test: quantitative RBC/WBC per mL
Blood Tests
- Complete blood count (CBC): may show mild anemia, leukocytosis
- Comprehensive metabolic panel: creatinine, urea (assess GFR and renal function), electrolytes (Na⁺, K⁺)
- Serum complement C3: will be low (consumed by immune complex deposition) — key diagnostic finding
- ASO titer (Antistreptolysin O): elevated, confirming recent Group A streptococcal infection; rises 7–14 days after onset, peaks at 3–4 weeks
- Anti-DNase B: also elevated in post-streptococcal disease (especially after throat infection)
- Throat culture: check for ongoing streptococcal infection
- Coagulation profile (PT, aPTT): baseline
Imaging
- Renal ultrasound: assess kidney size, echogenicity, rule out obstructive uropathy; kidneys typically enlarged in acute GN
Other
- ECG: given hypertension (BP 170/100), assess for LVH or hypertensive changes
- Fundoscopy: if severe hypertension — assess for hypertensive retinopathy
- Renal biopsy: generally NOT required in classic PSGN with typical presentation; indicated only if diagnosis is uncertain, no complement recovery by 8 weeks, or worsening renal function (rapidly progressive course)
Summary: This is a classic case of acute post-streptococcal glomerulonephritis in a young male, presenting with the nephritic triad (hematuria, edema, hypertension) following streptococcal tonsillitis with the characteristic 3-week latent period. Treatment is supportive — loop diuretics and antihypertensives for volume/BP control; benzathine penicillin G (1.2 million units IM) if active streptococcal infection persists. Prognosis is excellent in young patients, with symptoms resolving within days to weeks. — Goldman-Cecil Medicine
Answer this from the data
Here is the full interpretation of all laboratory data from the image, in the context of the previous case (19-year-old male with suspected Post-Streptococcal Glomerulonephritis):
CBC (Complete Blood Count)
| Parameter | Value | Normal | Interpretation |
|---|---|---|---|
| RBC | 4.0 × 10¹²/l | 4.5–5.5 | ↓ Mild anemia |
| Hb | 131 g/l | 130–160 | Low-normal |
| CI (Color Index) | 0.85 | 0.85–1.05 | Normal (normochromic) |
| WBC | 10.9 × 10⁹/l | 4–9 | ↑ Leukocytosis — active inflammation/infection |
| ESR | 38 mm/h | <15 | ↑ Elevated — acute inflammatory process |
| Stab cells | 2% | <6% | Normal |
| Segmented | 68% | 47–72% | Normal |
| Eosinophils | 3% | 1–4% | Normal |
| Monocytes | 4% | 3–11% | Normal |
| Lymphocytes | 23% | 19–37% | Normal |
CBC Conclusion: Mild normochromic anemia + leukocytosis + markedly elevated ESR — consistent with active immune-inflammatory process (PSGN).
Biochemistry
| Parameter | Value | Normal | Interpretation |
|---|---|---|---|
| Total protein | 60 g/l | 65–85 | ↓ Mild hypoproteinemia — protein loss in urine |
| Cholesterol | 4.1 mmol/l | <5.2 | Normal |
| Glucose | 5.7 mmol/l | 3.9–6.1 | Normal |
| Creatinine | 89 mmol/l* | 62–115 µmol/l | Normal-high range |
| Urea | 8.3 mmol/l | 2.5–8.3 | Upper limit — mild nitrogen retention |
| GFR | 97 ml/min | >90 | Normal (mildly reduced from ideal for age) |
Biochemistry Conclusion: Mild hypoproteinemia (from urinary protein loss). GFR 97 ml/min indicates that renal function is still preserved — this is early/mild glomerular injury. Urea at upper limit reflects early impairment of nitrogen excretion.
Urinalysis (General)
| Parameter | Value | Interpretation |
|---|---|---|
| Color | Meat-slop (reddish-brown) | Gross hematuria — classic "cola urine" of nephritic syndrome |
| Transparency | Cloudy | Abnormal — cells, casts, protein present |
| Specific gravity | 1.027 | ↑ High — concentrated urine / oliguria |
| Protein | 2.019 g/l | ↑ Proteinuria (significant) |
| Leukocytes | 10–12 /hpf | ↑ Mild leukocyturia (inflammatory) |
| Erythrocytes | 18–20 /hpf | ↑↑ Hematuria (microscopic confirmed on top of gross) |
| Hyaline cylinders | 8–10 /hpf | ↑ Hyaline casts — protein precipitation in tubules |
| Granular cylinders (acanthocytes) | 6–7–9 /hpf | ↑↑ Granular/RBC casts with acanthocytes — PATHOGNOMONIC for glomerulonephritis |
Urinalysis Conclusion: Classic nephritic urinary sediment — gross hematuria, significant proteinuria, RBC/granular casts with acanthocytes. This is the hallmark of glomerular disease.
Urine Analysis by Nechiporenko
| Parameter | Value | Normal | Interpretation |
|---|---|---|---|
| Leukocytes | 3000/ml | <2000/ml | ↑ Leukocyturia |
| Erythrocytes | 10,500/ml | <1000/ml | ↑↑↑ Significant hematuria |
| Cylinders | 300/ml | <20/ml | ↑↑↑ Cylindruria — glomerular damage confirmed |
Nechiporenko Conclusion: Massive erythrocyturia (10× normal) and cylindruria (15× normal) — unequivocally confirms glomerular origin of bleeding.
Overall Interpretation
All laboratory data are fully consistent with Acute Post-Streptococcal Glomerulonephritis (PSGN):
- Active inflammation: ↑ WBC, ↑ ESR
- Glomerular damage: RBC casts + acanthocytes in urine (pathognomonic), massive hematuria on Nechiporenko
- Protein loss: Mild hypoproteinemia + proteinuria 2 g/l
- Preserved renal function: GFR 97 ml/min — early stage, not yet progressed to renal failure
- Concentrated urine (SG 1.027) with oliguria — tubular response to volume retention
Next recommended tests (pending): serum C3 (expected ↓), ASO titer (expected ↑), Anti-DNase B — to confirm streptococcal etiology.
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