Acute Poststreptococcal Glomerulonephritis Research Articles

The novel Group A Streptococcus antigen SpnA combined with bead-based immunoassay technology improves streptococcal serology for the diagnosis of acute rheumatic fever

ObjectivesStreptococcal serology provides evidence of prior Group A Streptococcus (GAS) exposure, crucial to the diagnosis of acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis. However, current tests, which measure anti-streptolysin-O and anti-DNaseB antibodies, are limited by false positives in GAS endemic settings, and incompatible methodology requiring the two tests to be run in parallel. The objective was to improve streptococcal serology by combining the novel GAS antigen, SpnA, with streptolysin-O and DNaseB in a contemporary, bead-based immunoassay. MethodsRecombinant streptolysin-O, DNAseB and SpnA were conjugated to polystyrene beads with unique fluorescence positions so antibody binding to all three antigens could be detected simultaneously by cytometric bead array. Multiplex assays were run on sera collected in three groups: ARF; ethnically matched healthy children; and healthy adults. ResultsThe ability of the antigens to detect a previous GAS exposure in ARF was assessed using the 80th centile of the healthy children group as cut-off (upper limit of normal). SpnA had the highest sensitivity at 88%, compared with 75% for streptolysin-O and 56% for DNaseB. ConclusionsSpnA has favorable immunokinetics for streptococcal serology, and can be combined with anti-streptolysin-O and anti-DNaseB in a multiplex format to improve efficiency and accuracy.

Clinical Edema and Chest X-Ray Findings in Acute Poststreptococcal Glomerulonephritis

We report the results of a retrospective study evaluating clinical edema and chest X-ray findings in 17b patients with acute poststreptococcal glomeru¬lonephritis (APSGN), hospitalized in the Pediatric Nephrology Unit of Ujung Pandang General Hospital, from January 1, 1980 through December 31, 1990. Of the total 194 patients, only 176 fulfilled the criteria and could be evaluated. There were 98 boys (55,7%) and 78 girls (44.3%) aged between 1 year 9 months and 14 years, mostly be¬tween 6-12 years (72.8%). We found that edema of the palpebra was more frequently noted (98.9%) than that of the pretibia (71.6%), face (64.2%) and ascites (21.0%). This study showed evidence of cardiomegaly (84.1%), pulmonary vascular congestion (68.2%), pleural effusion (65.9%) and pulmonary' edema (48.9%). Our study results documented that roentgenographic abnormality of the chest of patients with APSGN, included each of the following findings, e.g., cardiomegaly, pleural effusion, pulmonary vascular congestion, and pulmonary edema, was significantly more frequent in patients with clinical evidence of severe edema than those with moderate and mild edema (p < 0.01).

M protein gene (emm type) analysis of group A Streptococcus isolates recovered during an acute glomerulonephritis outbreak in northern Western Australia

Certain M protein types of group A streptococcus (GAS) are known to cause acute post-streptococcal glomerulonephritis (APSGN). Outbreaks of APSGN can occur regularly in tropical regions but the emm types responsible are geographically and temporally diverse. GAS isolates from Western Australia (WA) were analysed for emm type and emm cluster during the period of increased APSGN activity in the tropical northern Kimberley region of WA. Although emm types 49, 75 and 108 and corresponding emm clusters E3, E6 and D4 were more common in WA during the outbreak there was no predominant circulating emm type or cluster found to correspond to the APSGN activity. This is consistent with the high diversity of GAS strains found during APSGN outbreaks in other countries. Potential vaccine coverage of the new 30-valent M-protein GAS vaccine was 70%.

Persistent hypocomplementemia in a 9 year old boy following acute poststreptococcal glomerulonephritis

Acute post-streptococcal glomerulonephritis (APSGN) is still common in our region and it is characterized by acute onset of edema, gross hematuria, hypertension, acute kidney injury and temporary hypocomplementemia with a preceding group A beta-hemolytic streptococcal infection.

Acute post-streptococcal glomerulonephritis in northwestern Ontario: A six-year retrospective study

BACKGROUND: Recent reports have described a high incidence of acute rheumatic fever in northwestern Ontario. However, the full burden of Group A streptococcal infection and its complications, including acute post-streptococcal glomerulonephritis (APSGN), in the region is not well understood. OBJECTIVE: To document the pediatric and adult incidence of APSGN in a predominantly First Nations population in northwestern Ontario. METHODS: The present study was a retrospective case series conducted over a six-year period in a population of 29,000 in northwestern Ontario. Adults and children meeting selection criteria for possible, probable, or confirmed APSGN within the study period were included. Outcome measures included patient demographics, comorbidities, investigations, clinical course, and status of renal function at last follow-up. RESULTS: The authors identified 10 pediatric and five adult cases of APSGN. The incidence rate of APSGN for children &lt;15 years of age was 20.8 cases per 100,000 person-years and, for adults, was 4.0 cases per 100,000 person-years. These rates are comparable with those observed in developing countries and more than triple the expected rate in the rest of Canada. CONCLUSION: The incidence rate of APSGN in northwestern Ontario exceeds the norm for a developed country. Inadequate, overcrowded housing and limited access to clean water experienced by many remote First Nations communities may drive the high burden of Group A streptococcal infection and its sequelae in this region.

C3 and C4 complements in glomerular disorders in children.

Seventy children who were hospitalized for kidney diseases in the Nephrological ward Department of Child Health, University of Indonesia, Jakarta were used in this study. Thirty seven patients sufferfng from acute poststreptococcal Glomerulonephritis (A.G.N.), 3 patients with Membranoproliferative Glomerulonephritis (M.P.G.N.) and 30 patients with Nephrotic Syndrome due to other causes were examined for complement concentration. A total of 80 samples were examined for C3 and 25 samples for C4 concentration using the immunediffusion plates. Almost all patients with A.G.N. and M.P.G.N. showed depression of C3. C4 concentration was normal except in 2 patients, 1 with A.G.N. and the other With M.P.G.N. This suggest activation of complement at the C3 level by the alternating pathway in most of the patients. C3 concentration in A.G.N. patients returned to normal after 8-10 weeks. In MPGN the depression was persistent in 2 patients, while in 1 patient it returned to normal level after 3 months of Immunosuppressive treatment.

A Retrospective Study of Acute Renal Failure in Children: Its Incidence, Etiology, Complications and Prognosis.

BackgroundAcute renal failure (ARF) developed due to various causes and may lead to significant morbidity and mortality among pediatric patients.ObjectivesThe study was conducted to determine the incidence, etiology, outcome of treatment and clinical presentation of ARF in pediatric patients in Somalia.MethodsComprehensive case history of 39 pediatric patients below 12 years of age, admitted with renal diseases in four tertiary care hospitals in Hargeisa and Borama cities in Somalia during December 2015 to November 2016. They were subjected to clinical investigation and laboratory test analysis based on the inclusion criteria of renal insufficiency characterized by serum creatinine level more than 1.5 mg/dl.ResultsARF was most commonly found in five to 12 years age group (53.8%) compared to infant (zero to one year) and pre-school (one to five years) children (23.08%). Mean age of presentation was 6.14 years. Male female ratio in this study was 1.2: 1. Most common presenting clinical feature in our study was oliguria (97.43%), swelling (69.2%), fever (84.1%), abdomen pain and nausea-vomiting (41.02%). Common clinical signs were edema (66.66%), altered sensorium (51.28%), hematuria (48.71%) and hypertension (38.46%). Snake bite and acute post streptococcal glomerulonephritis were the two most common causes of ARF in children in our study. Common complications were hypertension (38.46%), anemia (35.89%), hyperkalemia (25.64%) and infection (20.51%), all of which were within the previously reported range. The factors which correlated positively with increased mortality and morbidity were females with age below one year , etiology like septicemia and systemic lupus erythematosus (SLE), high peak serum creatinine concentration and complicated by disseminated intravascular coagulation (DIC).ConclusionMany causes of ARF are preventable and it should be possible to reduce mortality and morbidity due to ARF through purposive preventive measure and availability of the better medical facility.

A rare adult case of poststreptococcal acute glomerulonephritis with a retropharyngeal abscess.

Retropharyngeal abscess is an infection involving the retropharyngeal space which is posterior to the pharynx and oesophagus, and it results as a complication of a primary infection elsewhere in the head and neck including the nasopharynx, paranasal sinuses, or middle ear, which drain lymph to the retropharyngeal lymph nodes. Their lymph nodes are prominent in children and atrophy with age. Therefore, retropharyngeal abscess is most frequently encountered in children, with 75% of cases occurring before the age of 5 years, and often in the first year of life. We experienced a rare adult case of poststreptococcal acute glomerulonephritis with a retropharyngeal abscess, and conservative therapy ameliorated them. According to past reports, only one child with a retropharyngeal abscess and poststreptococcal acute glomerulonephritis has been presented at a conference to date; this is the first adult case of poststreptococcal acute glomerulonephritis with a retropharyngeal abscess. Retropharyngeal abscess can be fatal including airway compression, so it is important to remember retropharyngeal abscess in a case of poststreptococcal acute glomerulonephritis with severe symptoms of neck.

溶連菌感染二次症(とくに溶連菌感染後急性糸球体腎炎)の診断におけるストレプト・ザイムテスト及び ASLO テストの評価

溶連菌感染二次症(とくに溶連菌感染後急性糸球体腎炎)の診断におけるストレプト・ザイムテスト及び ASLO テストの評価

Causes and diagnostic significance of macroscopic hematuria in children and young adults

Background: Hematuria is common complaint brings patients to a physician. Macroscopic hematuria can be transient or persistent, and it may or may not associate with significant urinary system abnormalities. Objective: The objective of this study is to determine the major causes of macroscopic hematuria in ages less 20 years. Patients and Method: Descriptive case series study carrried out as a collaborative study in Tripoli during Januray 2013 - December 2014. Patients who presented with macroscopic hematuria file were studied retrospectively for gender, age, possible associated diseases as glomerulalar diseases, urinary tract infection (UTI), and others. Results: Out of 126 patients had macroscopic hematuria, 107 patients had the required data that achieved the study protocol. They were 72 cases (67.28%) males and 35 cases (32.71%), and their age ranged between (7 and 20 years). Macroscopic hematuria was more frequently reported at the age 7–13 years, and it was reported in (58.87%) due to the glomerular lesion, and in (41.12%) due to nonglomerular cause. Acute poststreptococcal glomerulonephritis (AGN) was the most common cause of macroscopic hematuria (53.27%), UTI was the second cause of macroscopic hematuria (28.97%), and renal stone was (9.34%) of total causes. Macroscopic hematuria due to trauma reported in 3 cases (6.8%), and in 5 cases (2.27%) due to IgA nephropathy. Conclusion: AGN and UTI are common causes of macroscopic hematuria. Urine microscopic examination is essential to differentiate between them before preceding to the other complicated, expensive, and invasive investigations.

Clinical characteristics of hypertensive encephalopathy in pediatric patients.

PurposeThe aim of this study was to assess the clinical characteristics of hypertensive encephalopathy according to the underlying etiologies in children.MethodsWe retrospectively evaluated 33 pediatric patients who were diagnosed as having hypertensive encephalopathy in Chonbuk National University Children's Hospital. Among the patients, 18 were excluded because of incomplete data or because brain magnetic resonance imaging (MRI) was not performed. Finally, 17 patients were enrolled and divided into a renal-origin hypertension group and a non-renal-origin hypertension group according to the underlying cause. We compared the clinical features and brain MRI findings between the 2 groups.ResultsThe renal group included renal artery stenosis (4), acute poststreptococcal glomerulonephritis (2), lupus nephritis (2), and acute renal failure (1); the nonrenal group included essential hypertension (4), pheochromocytoma (2), thyrotoxicosis (1), and acute promyelocytic leukemia (1). The mean systolic blood pressure of the renal group (172.5±36.9 mmHg) was higher than that of the nonrenal group (137.1±11.1 mmHg, P<0.05). Seizure was the most common neurologic symptom, especially in the renal group (P<0.05). Posterior reversible encephalopathy syndrome (PRES), which is the most typical finding of hypertensive encephalopathy, was found predominantly in the renal group as compared with the nonrenal group (66.6% vs. 12.5%, P<0.05).ConclusionWe conclude that the patients with renal-origin hypertension had a more severe clinical course than those with non-renal-origin hypertension. Furthermore, the renal-origin group was highly associated with PRES on brain MRI.

Posterior reversible encephalopathy syndrome in children: a case series

Posterior reversible encephalopathy syndrome is characterized by hypertension, seizure, headache, clouding of consciousness, and visual disturbance, and is diagnosed in the presence of typical lesions on magnetic resonance imaging. We retrospectively evaluated five patients who were diagnosed as having posterior reversible encephalopathy syndrome and followed up in Meram Medical Faculty, Pediatric Intensive Care and Hematology wards, between January 2010 and January 2014. We reviewed the demographic and clinical data, and neuroimaging findings. The primary diseases of the subjects included acute lymphocytic leukemia (n=2), Henoch-Schönlein purpura (n=1), systemic lupus erythematous (n=1), and acute poststreptococcal glomerulonephritis (n=1). The mean age was 10±4.58 years (range, 5-14 years). Acute elevation of blood pressure was found in all patients (n=5). Initial neurologic manifestations included seizure, clouding of consciousness, headache, and visual disturbance. After the diagnosis was made through clinical evaluations and magnetic resonance imaging, complete clinical recovery was obtained in all patients with the appropriate therapeutic approach. In conclusion, posterior reversible encephalopathy syndrome should be considered in the differential diagnosis of patients who present with encephalopathy and underlying diseases such as nephritis, vasculitis, malignancy accompanied by hypertension, and a history of use of medication.

Erythrocyturia and proteinuria conversion in post-streptococcal acute glomerulonephritis

Background Acute glomerulonephritis (AGN) is a sudden onsetof macroscopic hematuria and edema. The chronic post-strepto-coccal acute glomerulonephritis (PSAGN) can be predicted if mi-croscopic hematuria, proteinuria, and low serum complement C3level are present for a period exceeding six months after initial onsetof illness. It is prudent to follow the course of PSAGN until proteinurianormalizes and microhematuria disappears in urinalysis.Objective To acquire the time of erythrocyturia and proteinuriaconversion in post-streptococcal acute glomerulonephritis (PSAGN)among children.Methods A retrospective cohort study on children with PSAGNwas conducted in the Pediatric Outpatient Clinic and Ward atSanglah Hospital, Denpasar, Bali from January 2001-December2003. All subjects were recorded for clinical and laboratory signs,including initial symptoms, history of previous streptococcal infec-tions, blood pressure, complete blood count, serum albumin, ASTOtiter, complement C3 level, BUN, and serum creatinin. Erythrocyt-uria and proteinuria follow-ups were done by recording urinalysisfindings for a six-month period after initial onset.Results Thirty subjects 21 boys and 9 girls, mean age 8.7 (SD 2.5)years] with PSAGN were enrolled in the study, 16 had hematuria withedema. Twenty-one subjects had the history of upper respiratory tractinfections and 9 with skin infections. Mean systolic blood pressure was141.3 (SD 21.8) mmHg, mean diastolic blood pressure was 90.8 (SD16.3) mmHg, mean ASTO titer was 1103.3 (SD 686.1) IU/ml, and meancomplement C3 level was 42.2 (SD 15.5) mg/dl. Urinalysis monitoringshowed 2/30, 9/30, 12/30, 22/30, 27/30 subjects had conversion he-maturia at the first, second, third, fourth, and fifth month, respectively.Median duration of erythrocyturia conversion was 4.0 months (95% CI:3.53-4.47). There were 11/30, 18/30, 21/30, 23/30, 25/30, 26/30 sub-jects with proteinuria conversion at the first, second, third, fourth, fifth,and sixth month, respectively. Median duration of proteinuria conver-sion was 2.0 months (95% CI: 1.25-2.75).Conclusion Three out of 30 children remained with persistenthematuria and 4 of 30 remained with persistent proteinuria

Comparative Efficacy of Calcium Channel Blocker and ACE Inhibitor in the Treatment of Acute Hypertension in Acute Post Streptococcal glomerulonephritis

1.1.Background: Acute Post Streptococcal Glomerulonephritis (APSGN) refers to the immunologic mechanism which triggers inflammation and proliferation of glomerular tissue, characterized by a relatively abrupt onset of variable degrees of gross haematuria, edema, hypertension and renal insufficiency. Patient may develop encephalopathy and or heart failure due to hypertension or hypervolemia as a complication. 1.2.Objectives:The objective of the study was to find out the better drug for hypertension and/or its complications in terms of effectiveness, side effects and compliance. 1.3.Methods: This randomized clinical trial was conducted among 60 children aged3-12 years, who were suffering from Acute Streptococcal Glomerulonephritis (APSGN) with hypertension and/or its complications. After enrolment, the patients were randomly divided into two groups as group A and group B. Both groups received the standard management of APSGN. In addition, children in group A received captopril (dose 0.5 up to 6mg/kg/day) and children in group-B received Nifedipine (0.25 up to 0.5 mg/kg/day). Their effectiveness in relation to timing of response, duration of therapy, duration of hospital stay, side effects and cost effectiveness of the drugs was assessed and compared statistically, and at p value of <0.05 the result was considered significant. 1.4.Results: Most patients had high systolic and high diastolic blood pressure. In captopril group mean systolic and mean diastolic blood pressure were 134.8±9.3 mm of Hg and 94.97±6.3 mm of Hg respectively. In Nifedipine group mean systolic and mean diastolic blood pressure 131.96±8.1 mm of Hg and 92.8±9.1mm of Hg respectively. The mean time needed to normalize both systolic and diastolic blood pressure (<95th percentile) in group A (Captopril) was 4.98±2.07 days and that of group B (Nifedipine) was 3.09±1.83 days. The difference between two group was statistically significant (p<0.05). Duration of antihypertensive therapy was longer in captopril group than in the Nifedipine group (<0.05). There were no significant side effects. 1.5.Conclusion: It is obvious from the study that Nifedipine controlled BP earlier and reduced the duration of hospital stay compared to captopril. For the control of hypertension in APSGN patients, Nifedipine is a better drug. 1.6.Recommendation: Nifedipine should be used in controlling hypertension in acute post streptococcal glomerulonephritis.

Prognostic factors for mortality in pediatric acute poststreptococcal glomerulonephritis

Background Acute post-streptococcal glomerulonephritis (APSGN) is one of the most common causes of glomerular disease in developing countries, including Indonesia. It can lead to end stage renal failure and higher mortality rates. To decrease morbidity and mortality, it is important to understand the prognostic factors affecting the disease.Objective To identify prognostic factors affecting outcomes in pediatric APSGN patients.Methods Study data were collected from medical records of patients with APSGN hospitalized in Wahidin Sudirohusodo Hospital, Makassar in 2009-2013. Possible prognotic factors analyzed were gender, age, nutritional status, level of consciousness, as well as proteinuria, hemoglobin, serum albumin, urea, and creatinine levels.Results Of 86 subjects, 82 (95.3%) survived and 4 (4.7%) died. Fifty-three (61.6%) patients were male and 33 (38.4%) were female. Subjects’ ages ranged from 3.42 to 14.67 years, with a mean age of 9.36 years. Multivariate analysis revealed serum creatinine level &gt;1.5 mg/dL to be an independent prognostic factor for mortality in children with APSGN (AOR 15.43; 95%CI 1.31 to 181.7; P=0.03).Conclusion High serum creatinine level is an independent prognostic factor for poor outcomes in children with APSGN. [Paediatr Indones. 2016;56:166-70.].

Serum myeloid-related protein 8/14 in minimal change- and glomerulonephritis-related nephrotic syndrome.

Myeloid-related protein 8/14 (MRP8/14) forms stable heterodimers and is the major calcium-binding protein secreted by activated granulocytes and monocytes. We evaluated whether serum MRP8/14 level is a useful indicator for a differential diagnosis of glomerulonephritis (GN)- and minimal change disease (MC)- related nephrotic syndrome (NS). Serum MRP8/14 complex was evaluated in 37 NS patients with MC or GN. These patients were divided into two groups. Group 1 consisted of 13 NS patients with MC, and group 2 consisted of 24 NS patients with GN. Group 2 was further divided into four subgroups: IgA nephropathy (IgAN; n = 5), Henoch-Schönlein purpura nephritis (HSPN; n = 6), focal segmental glomerulosclerosis (FSGS; n = 12), and acute GN Poststreptococcal acute glomeruloNephritis (PSAGN; n = 1). The clinical manifestations, laboratory findings, serum MRP8/14 level, and renal accumulation of MRP8 were investigated for each group. No significant inter-group differences were observed for serum total protein, serum albumin, or blood urea nitrogen and urinary protein excretions. Mean serum MRP8/14 in the IgAN, HSPN, FSGS, and PSAGN groups was higher than in group 1. Further, the mean glomerular and interstitial MRP8 staining scores in the IgAN, HSPN, and PSAGN groups were higher than in group 1. Serum MRP8/14 level may be a useful indicator for differential diagnosis between GN- and MC- related NS.

The clinical manifestations of children with endocapillary proliferative glomerulonephritis with isolated C3 deposition

Objective To study the patients' clinical characteristics and prognosis when only C3 deposition exists in endocapillary proliferative glomerulonephritis and try to understand deeply the role of C3 in kidney damage deeply. Methods The patients who were diagnosed with endocapillary proliferative glomerulonephritis but only had C3 deposited in immunofluorescence (to avoid false positive, C3≥2+ was included) were selected from Beijing Children's Hospital Affiliated to Capital Medical University during November 2010 to October 2014.Their clinical manifestations, laboratory examinations, treatments, prognosis, and pathological changes were analyzed, and literature review was performed.Their clinical characteristics and prognosis were summarized. Results There were 11 patients diagnosed with endocapillary proliferative glomerulonephritis which had only C3 deposition (≥2+ ). Nine of them had onset with acute nephritis syndrome (81.8%), and 2 cases presented recurrent paroxysmal gross hematuria(18.2%). Seven cases were diagnosed with acute post streptococcal glomerulonephritis (63.6%). Eleven cases' clinical manifestations were relatively severe, and the complement C3 was significantly lower than the normal (100.0%). Their light microscope showed capillary proli-ferative glomerulonephritis, and the electron microscope showed the immune complexes were deposited in the endothelium, the epithelium or the mesangial area.The patients received corresponding treatment respectively, and all the patients had good prognosis during following up of 7 months up to 39 months. Conclusions Streptococcus infection is a common cause in endocapillary proliferative glomerulonephritis with only C3 deposition.The clinical manifestations of some children are similar to post streptococcal glomerulonephritis but relatively severe.Only deposition of C3 without IgG may be involved in another complement activation mechanism. Key words: Complement 3; Endocapillary proliferative glomerulonephritis; Streptococcus infection

Acute Post-Streptococcal Glomerulonephritis in Children

Acute post-streptococcal glomerulonephritis is the most common form of glomerulonephritis in children, continues to be a major concern for pediatricians and nephrologists worldwide. The disease is caused by prior streptococcal infection caused by -hemolytic streptococcus of A group. Nephritis-associated plasmin receptor and streptococcal pyrogenic exotoxin B are considered to be major renotrophic antigens. Clinical findings of the disease can vary from asymptomatic gross hematuria to the full-blown acute nephritic syndrome (edema, gross hematuria, hypertension, renal failure). The main laboratory findings of acute post-streptococcal glomerulonephritis include an abnormal common urine analysis (dysmorphic erythrocytes, varying degrees of proteinuria, red blood cell casts, and segmentonuclear neutrophils), an elevated titer of antibodies to antistreptococcic antigens, and hypocomplementemia. Treatment of patients is mainly supportive and is focused upon the elimination of hypervolemia and its complications (edema, hypertension). In this situation, the most effective agents are loop diuretics and antihypertensive agents. The prognosis in children is generally favourable. The review analyses the current understanding of the pathogenesis, clinical manifestations, diagnosis, treatment and prognosis of acute post-streptococcal glomerulonephritis.

Rationale and design of the African group A streptococcal infection registry: the AFROStrep study

IntroductionGroup A β-haemolytic Streptococcus (GAS), a Gram-positive bacterium, also known as Streptococcus pyogenes, causes pyoderma, pharyngitis and invasive disease. Repeated GAS infections may lead to autoimmune diseases such as acute...

A Posterior Reversible Encephalopathy Case Releated to Acute Post streptococcal Glomerulonephritis

Acute poststreptococcal glomerulonephritis (APSGN) is one of the most common causes of acute hypertension in children. Posterior reversible encephalopathy Syndrome (PRES) is a clinico-radiological picture which emerges commonly in the setting of known hypertension or use of immune suppressive agents. Characteristic symptoms of PRES include headache, vomiting, visual disturbances, changes in consciousness and seizures. The most common abnormality on neuroimaging is bilateral edema involving the white and grey matter in the posterior regions of cerebral hemispheres, especially in the parietooccipital regions. We reported herein a 11-year male patient who presented with acute headache, change in consciousness, seizure and was diagnosed PRES -related APSGN.