Quiz page. Acute rheumatic fever with concomitant poststreptococcal glomerulonephritis.
Sinha R, Al-AlSheikh K, Prendiville J, Magil A, Matsell D..
Excerpt:
A 7-year-old girl presented with a 6-week history of persistent fever, fleeting pruritic rash, arthralgia, and gross hematuria. Two weeks preceding this, she and her family had experienced severe upper respiratory symptoms, and streptococcal pharyngitis was diagnosed in her mother. On examination, the patient had normal vital signs, mild peripheral edema, and a 2 to 3/6 systolic murmur localized over the cardiac apex. The rash was migratory, primarily involving trunk and limbs.
Hemoglobin level was 12.7 g/dL (127 g/L), white blood cell count was 15 X 103/μL (14.5 109/L), and C-reactive protein level was 14.5 g/dL (145 mg/ L). Serum electrolyte, blood urea nitrogen, and creatinine levels were normal. Urinalysis was 4+ for protein and showed greater than 100 red blood cells/high-power field with red blood cell casts. Her complement 3 (C3) level was low at 68 mg/mL (0.68 g/L), but C4 level was normal at 24 mg/mL(0.24 g/L). Results for all cultures, including throat swab, were negative. Initial antistreptolysin O titer was increased at 250 IU/L and a titer repeated in a week was 325 IU/L. Echocardiography showed a small pericardial effusion and mild mitral regurgitation. Significant proteinuria and persistent hematuria in this unusual setting led to a renal biopsy.
Photos are presented of the rash on the lower limbs, of a renal biopsy specimen under the light microscope, and a renal biopsy specimen showing a lesion under electron microscopy.
The symptoms are explained and a diagnosis offered.
Am J Kidney Dis. 2007 Jul;50(1):A33-5.
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