Atypical streptococcal nephritis.

Abstract

Poststreptococcal acute glomerulonephritis is most often associated with skin and throat infections. It is important, however, to remember that other streptococcal infections may cause acute glomerulonephritis. Two cases of atypical glomerulonephritis are reported. Case report.Patient 1. A 6-year-old male was admitted with a chief complaint of swelling around the left eye and anorexia for 1 day. On admission physical examination revealed a temperature of 103°F and circumferential swelling around the left eye with erythema; his left eyelids were closed; there was tenderness around the periorbital area and decreased upward gaze. There was no eye discharge or conjunctival injection. A mucoid, whitish discharge from the left nostril was present. Laboratory results on admission included a white blood cell count of 14.5 × 103/mm with 92% polymorphonuclear leukocytes, 5% lymphocytes and 3% monocytes; hemoglobin was 17.4 g/dl and erythrocyte sedimentation rate was 40 mm/h. Urinalysis was normal. Computerized tomography of the orbits revealed ethmoid sinusitis with preseptal cellulitis and changes in the left orbital muscle consistent with edema and cellulitis. He was admitted with a diagnosis of left preseptal cellulitis and management with intravenous cefuroxime was started. A left external ethmoidectomy was performed. Intraoperative cultures of purulent fluid grew group A beta-hemolytic Streptococcus. Blood cultures and a throat culture were negative. The patient became afebrile after a 4-day course of intravenous antibiotics but developed microscopic hematuria, mild ascites and presacral edema. He also developed hypertension (blood pressure, 140/104 mm Hg). Urine culture was negative. Serum complement assays revealed a C3 of 16 mg/dl and a C4 of 18 mg/dl. He was diagnosed with poststreptococcal glomerulonephritis. The hypertension was controlled with furosemide and nifedipine. The patient recovered fully. Patient 2. A 9-year-old male was admitted with chief complaint of fever, abdominal pain for 5 days and vomiting on the day of admission. There was no history of diarrhea. His temperature was 104.9°F and he appeared ill, in pain and mildly dehydrated. The abdominal examination revealed diffuse tenderness with guarding, rebound tenderness on palpation and a positive psoas sign. Laboratory results included a white blood cell count of 12.3 × 103 cells/mm3 with a differential of 76% polymorphonuclear cells, 10% band forms, 11% lymphocytes and 3% monocytes. The hemoglobin was 11.6 mg/dl. Prothrombin and partial thromboplastin times, electrolytes and urinalysis were normal. His disorder was diagnosed as acute appendicitis and he was given intravenous hydration and ampicillin, gentamicin and metronidazole. He underwent appendectomy; operative findings revealed suppurative appendicitis with early peritonitis. Peritoneal fluid culture grew group A beta-hemolytic Streptococcus and Neisseria sica. The patient remained febrile postoperatively and developed microscopic hematuria with hypertension (blood pressure 140/95 mm Hg). The Streptozyme® agglutination test was positive and serum complement values of C3 and C4 were 33 and 11 mg/dl, respectively. The diagnosis was poststreptococcal glomerulonephritis. The hypertension was controlled with furosemide and nifedipine. Fevers persisted and he was subsequently diagnosed with a pelvic abscess that was percutaneously drained. Abscess cultures were sterile. He recovered fully. Discussion. Group A beta-hemolytic Streptococcus infection may present with a variety of clinical manifestations. Acute nephritis usually follows throat infections, impetigo or other forms of cutaneous streptococcal infections1 Unlike rheumatic fever and group A beta-hemolytic Streptococcus sepsis that have reemerged in the United States with several outbreaks since the late 1980s, nephritis is somewhat less prevalent than in the past.2-4 Nephritis continues to be relatively prevalent in areas with tropical climates.5 These two cases are a reminder that acute poststreptococcal glomerulonephritis, although rare, can occur after invasive infection and may not be limited to skin and throat infections. Luis Rodriguez, M.D.; Melvin Gertner, M.D. Elmhurst Hospital Center Elmhurst, NY