| Home | E-Submission | Sitemap | Contact Us |  
Child Kidney Dis > Volume 20(1); 2016 > Article
Kim: Clinical Manifestation Patterns and Trends in Poststreptococcal Glomerulonephritis

Abstract

Poststreptococcal glomerulonephritis (PSGN) is one of the most recognized diseases in pediatric nephrology. Typical clinical features include rapid onset of gross hematuria, edema, and hypertension, and cases are typically preceded by an episode of group A β-hemolytic streptococcus pharyngitis or pyoderma. The most common presenting symptoms of PSGN are the classic triad of glomerulonephritis: gross hematuria, edema, and hypertension . However, patients with PSGN sometimes present with unusual or atypical clinical symptoms that often lead to delayed diagnosis or misdiagnosis of the disease and increased morbidity. Additionally, the epidemiology of postinfectious glomerulonephritis (PIGN), including PSGN, has changed over the past few decades. This paper reviews atypical clinical manifestations of PSGN and discusses the changing demographics of PIGN with a focus on PSGN.

Case 1. A 10-year-old boy presented with acute headache, altered mental state, and generalized seizure. He had hypertension and microscopic hematuria, and MRI showed lesions suggestive of Posterior Reversible Encephalopathy Syndrome (PRES). Analysis indicated that the antistreptolysin-O (ASO) titer was increased and complement C3 titer was decreased. The patient was diagnosed with PRES-related hypertensive poststreptococcal glomerulonephritis (PSGN).
Case 2. A 9-year-old boy was transferred from another hospital with dyspnea, and plain chest film indicated alveolar infiltrates and bilateral pleural effusions. Urinalysis and blood pressure measurements showed microscopic hematuria and hypertension. The elevated serum ASO titer and decreased serum complement C3 level confirmed the diagnosis of PSGN.
The clinical manifestations of the two cases differed from typical clinical features of PSGN. The most common presenting symptoms of PSGN are the classic triad of glomerulonephritis: gross hematuria, edema, and hypertension. However, PSGN can present with unusual or atypical clinical symptoms that often lead to delayed diagnosis or misdiagnosis, which increases morbidity [1,2].
In addition, the epidemiology of postinfectious glomerulonephritis (PIGN), including PSGN, has changed over the past few decades [3-5].
This is a review of atypical clinical PSGN manifestations and a discussion of the changing PIGN demographics, with focus on PSGN.

Atypical Clinical Features of Post-streptococcal Glomerulonephritis (PSGN)

A number of patients with PSGN may only have subclinical involvement, with microscopic hematuria, normal to mildly elevated BP, and no obvious edema. These patients may not seek medical attention, but the incidence can be detected during school urine screening tests. Hypertension and its accompanying symptoms, such as headaches or seizures, without typical urinary findings at presentation, can also be misdiagnosed, which causes a delay of treatment [1,2]. In some cases, diagnosis is confirmed by renal biopsy and presence of a typical Henoch-Schönlein purpura (HSP) rash with acute nephritis [6,7].
A delay in the diagnosis of PSGN is more common in children that do not have a history of antecedent group A β-hemolytic streptococcus (GAS) infection and have microscopic hematuria. Most patients present with findings due to volume overload, which include hypertension, edema, and pulmonary edema [1].
Dr. Watanabe classified atypical PSGN manifestation into three categories: Concurrence of immune-mediated diseases, non-immune-mediated conditions, and atypical clinical manifestations or courses [8].

1. Concurrence of immune-mediated disease

The co-occurring immune-mediated diseases include acute rheumatic fever, vasculitis, and immune thrombocytopenic purpura (ITP).
Acute rheumatic fever is an immune mediated disease that can follow a GAS infection along with PSGN. However, the epidemiology and immunology of the two diseases are different, and co-occurrence of the two diseases in the same patient is rare [9]. Gibney et al. first reported a case with simultaneous acute rheumatic fever and biopsy-proven PSGN [10]. Since then 17 patients with co-occurrent acute rheumatic fever and PSGN have been reported [11]. It is not clear why simultaneous PSGN and acute rheumatic fever are rare. One explanation may be that only about 15 of the more than 80 known M serotypes of GAS have both nephritogenic and rheumatogenic antigenic features [9].
Vasculitis is not a frequent disorder correlated with GAS infection. However there have been several articles of HSP [6] or Henoch-Schönlein purpura with nephritis (HSPN) [7]. Despite the complete pathogenic part of GAS infection that devotes to the evolution of vasculitis is not clear, an immune complex-mediated mechanism caused by GAS infection has been speculated [12].
Childhood ITP, an autoimmune disease with antibodies detectable against platelet surface antigens, often occurs after a viral infection, such as influenza, Epstein-Barr, varicella zoster, rubella virus [13] but may also be preceded by a bacterial infection [14]. Since the first reported ITP cases in two patients with PSGN [15], several cases of thrombocytopenia in patients with PSGN have also been reported [13,14]. Muguruma et al. postulated about the pathogenesis of correlated diseases based on development of antibodies that were cross-response against GAS and platelets [14].

2. Non-immune-mediated conditions

Non-immune-mediated conditions of PSGN include posterior reversible encephalopathy syndrome (PRES) and thrombotic microangiopathy.
Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome (RPLS), is a recently-described brain disorder with typical radiological findings of bilateral gray and white matter abnormalities in the posterior regions of the cerebral hemispheres and cerebellum [16,17]. The clinical symptoms include headache; decreased alertness; mental abnormalities such as confusion and diminished spontaneity of speech; behavior changes that range from drowsiness to stupor, seizures, vomiting; and visual perception abnormalities, such as cortical blindness [18]. The causes of PRES can vary, but it is commonly attributed to acute increase in blood pressure, renal failure, fluid retention, and treatment with immunosuppressive drugs [17]. Although the pathophysiology of PRES is not completely understood, it is believed that severe hypertension or other causes of PRES induce breakdown in cerebral autoregulation, which leads to leakage of fluid into the brain parenchyma. The leakage of fluid into the brain parenchyma is detected as vasogenic edema on neuroimaging studies [19]. The prognosis of PRES is generally benign, but delay in diagnosis and treatment can result in permanent sequelae to the affected brain tissues [17].
Thrombotic microangiopathy (TMA) is a pathological process that involves thrombocytopenia, microangiopathic hemolytic anemia, and microvascular occlusion. TMA is common in hemolytic uremic syndrome (HUS) associated with shiga toxin or invasive pneumococcal infection, atypical HUS (aHUS), thrombotic thrombocytopenic purpura (TTP), and other disorders including malignant hypertension [20]. Histologic features of TMA include vessel wall swelling, thickening and separation of the endothelial cell from the basement membrane, aggregation of substance in the subendothelial space, intraluminal platelet thrombosis, partial or complete vascular luminal occlusion, and red blood cell fragmentation [21].
There have been at least 10 cases describing TMA associated with PSGN [22-24]. All patients exhibited hypertension, and renal replacement therapy was performed in 3 patients. Renal pathology revealed the appearance of both PSGN and TMA in 3 patients and showed PSGN features without characteristics of TMA in 7 patients. The outcome in all patients was good.
Although the precise pathogenesis of TMA in patients with PSGN is not clear, 2 causes have been speculated: serious hypertension and streptococcal neuraminidase [22,23]. HUS has been reported as a consequence of severe hypertension, regardless of the cause. If severe hypertension is temporary, histological features of TMA are not present. But hypertension becomes malignant, pathologic lesions show characteristics of TMA [22]. Another available explanation of TMA in PSGN is adjustment of vascular endothelial cells by streptococcal neuraminidase. Circulating neuraminidase triggers antigen-antibody interaction and may injure the vascular endothelial cells, leading to the clinical manifestations of HUS [23].

3. Atypical clinical manifestations or courses

Atypical clinical manifestations or courses of PSGN are acute nephritis without definite urinary abnormalities and relapse of the illness.
Patients with PSGN usually show hematuria and proteinuria. But there are several reports of histologically proven PSGN patients with minimal or no urinary abnormalities [25-27]. Most patients showed edema and hypertension, and some of them exhibited pulmonary congestion or edema. All patients improved completely without any residue. The reasons for the normal or minimal urinary abnormalities during the course of PSGN is not clear [26,27].
Recurrence of PSGN is a rare occurrence, probably because of the relatively limited number of nephritogenic strains of streptococci and the acquirement of protective immunity against a nephritogenic streptococcal antigen after an initial episode of PSGN [28]. Although incidences of recurrent PSGN have been reported to range from 0.7% to 7.0% in several clinical studies, and a few cases of recurrent PSGN have been reported [28-30], the exact pathophysiological mechanisms that cause recurrence of PSGN remain unclear [28]. Relapse of PSGN in some patients probably caused by defect of a natural immune response against nephritogenic streptococcal components such as NAPlr [28]. Recently, a patient with selective IgA deficiency exhibited two episodes of PSGN [30]. It might suggest that a failure of IgA defenses may also lead to streptococcal re-infection and cause recurrent PSGN. Because unusual or atypical features of PSGN can lead to diagnostic delays or misdiagnosis of the disease, early perception is important to ensure that the patient receives acceptable treatment.

Changing Trends of Poststreptococcal Glomerulonephritis

Poststreptococcal glomerulonephritis (PSGN) is one of the oldest recognized renal diseases. More than 200 years ago, Wells described the clinical features of dark and scanty urine after scarlet fever, and this postscarlatinal disorder was termed acute glomerulonephritis. In the 1920s, it was discovered that scarlet fever was caused by an infection with β-hemolytic streptococcus, and PSGN became the etiologically correct term [31]. It is widely acknowledged that the incidence of PSGN has decreased in the past few decades. In addition, changing patterns in the occurrence of PSGN over the last few decades have been described in studies from many countries, including the United States, Singapore, and China [32-34].
The reasons for the decreased incidence of PSGN have not been clearly defined. Some possible reasons include the widespread use of antibiotics, changes in etiological pathogens, altered susceptibility of the host, better health care, and improved socioeconomic and nutritional conditions [32-35]. In addition, in Korea, several single-center studies from different areas showed declining incidence and sporadic outbreaks [4,5,36].
Despite the reduction in the worldwide incidence of PSGN, epidemics and clusters of cases continue to appear in several regions of the world, and the burden of PSGN ranges between 9.5 and 28.5 new cases per 100,000 individuals per year [3,37]. Sporadic cases of PSGN account for 21% (4.6-51.6%) of children admitted to the hospital with acute renal failure in developing countries [3]. In these developing countries, PSGN occurs primarily in children [38] and young adults [39].
In comparison, patients in western countries tend to be elderly [40]. An epidemiological evaluation from Italy showed an incidence of PIGN in elderly patients that was more than twice that of the pediatric population [41]. This shift is likely due to increased life expectancy and increased severity of infections in the elderly population with predisposing factors (diabetes, malignancy, and vasculopathy) [42].
The bacteriology of adult PIGN differs from the typical childhood disease. Currently, non-streptococcal infections, including staphylococcal and Gram-negative bacilli infections, are known to cause PIGN, particularly in western adults who are immunocompromised. Staphylococcus has become as common as Streptococcus in developed countries, and it is 3-fold more common in elderly patients. Diabetes is a major risk factor of Staphylococcus-related GN, reflecting the increased skin and mucosal colonization in diabetics [43].
The pathogenesis of PIGN requires additional study to determine distinguishing characteristics that differentiate it from classic PSGN; currently, various clinical and pathologic profiles have been described, including abundant IgA deposits and aggressive progression to ESRD [44].
PIGN should always be considered in the differential diagnosis of elderly patients with acute renal failure and active urinary sediment. Additionally, familiarity with its atypical presentations and evolution is crucial for a correct diagnosis and prompt treatment.

References

1. Pais PJ, Kump T, Greenbaum LA. Delay in diagnosis in poststreptococcal glomerulonephritis. J Pediatr. 2008;153: 560-4.
crossref pmid
2. Kim K, Hwang H. Atypical Clinical Features of Acute Poststreptococcal glomerulonephritis (APSGN) in Children. Pediatr Nephrol. 2010;25: 1870.

3. Rodriguez-Iturbe B, Musser JM. The current state of poststreptococcal glomerulonephritis. J Am Soc Nephrol. 2008;19: 1855-64.
crossref pmid
4. Yu R, Park SJ, Shin JI, Kim KH. Clinical patterns of acute poststreptococcal glomerulonephritis: a single center’s experience. J Korean Soc Pediatr Nephrol. 2011;15: 49-57.
crossref
5. Kuem SW, Hur SM, Youn YS, Rhim JW, Suh JS, Lee KY. Changes in acute poststreptococcal glomerulonephritis: An observation study at a single Korean hospital over two decades. Child Kidney Dis. 2015;19: 112-7.
crossref
6. Goodyer PR, de Chadarevian JP, Kaplan BS. Acute poststreptococcal glomerulonephritis mimicking Henoch-Schönlein purpura. J Pediatr. 1978;93: 412-5.
crossref pmid
7. Matsukura H, Ohtsuki A, Fuchizawa T, Miyawaki T. Acute poststreptococcal glomerulonephritis mimicking Henoch-Schönlein purpura. Clin Nephrol. 2003;59: 64-5.
crossref pmid
8. Toru Watanabe. Atypical clinical manifestations of acute poststreptococcal glomerulonephritis. In: In Prabhakar S (ed.), , editors. An Update on Glomerulopathies - Clinical and Treatment Aspects. In Tech, 2011: 151-68.

9. Lin WJ, Lo WT, Ou TY, Wang CC. Haematuria, transient proteinuria, serpiginous-border skin rash, and cardiomegaly in a 10-year-old girl. Diagnosis: Acute post-streptococcal glomerulonephritis associated with acute rheumatic pericarditis. Eur J Pediatr. 2003;162: 655-7.
crossref pmid
10. Gibney R, Reineck HJ, Bannayan GA, Stein JH. Renal lesions in acute rheumatic fever. Ann Intern Med. 1981;94: 322-6.
crossref pmid
11. Sinha R, Al-AlSheikh K, Prendiville J, Magil A, Matsell D. Acute rheumatic fever with concomitant poststreptococcal glomerulonephritis. Am J Kidney Dis. 2007;50: A33-5.

12. Ritt M, Campean V, Amann K, Heider A, Griesbach D, Veelken R. Transient encephalopathy complicating poststreptococcal glomerulonephritis in an adult with diagnostic findings consistent with cerebral vasculitis. Am J Kidney Dis. 2006;48: 489-94.
crossref pmid
13. Tasic V, Polenakovic M. Thrombocytopenia during the course of acute poststreptococcal glomerulonephritis. Turk J Pediatr. 2003;45: 148-51.
pmid
14. Muguruma T, Koyama T, Kanadani T, Furujo M, Shiraga H, Ichiba Y. Acute thrombocytopenia associated with post-streptococcal acute glomerulonephritis. J Paediatr Child Health. 2000;36: 401-2.
crossref pmid
15. Kaplan BS, Esseltine D. Thrombocytopenia in patients with acute post-streptococcal glomerulonephritis. J Pediatr. 1978;93: 974-6.
crossref pmid
16. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334: 494-500.
crossref
17. Yun BS, Lee SJ, Kim Y, Kim KH, Jung HJ. A Case of Posterior Reversible Encephalopathy Syndrome with Post Streptococcal Glomerulonephritis. J Korean Child Neurol Soc. 2008;16: 229-34.

18. Kwon S, Koo J, Lee S. Clinical spectrum of reversible posterior leukoencephalopathy syndrome. Pediatr Neurol. 2001;24: 361-364.
crossref pmid
19. Fugate JE, Claassen DO, Cloft HJ, Kallmes DF, Kozak OS, Rabinstein AA. Posterior reversible encephalopathy syndrome:associated clinical and radiologic findings. Mayo Clin Proc. 2010;85: 427-32.
crossref pmid pmc
20. Barbour T, Johnson S, Cohney S, Hughes P. Thrombotic microangiopathy and associated renal disorders. Nephrol Dial Transplant. 2012;27: 2673-85.
crossref pmid pmc
21. Keir L, Coward RJ. Advances in our understanding of the pathogenesis of glomerular thrombotic microangiopathy. Pediatr Nephrol. 2011;26: 523-33.
crossref pmid pmc
22. Duvic C, Desramé J, Hérody M, Nédélec G. Acute poststreptococcal glomerulonephritis associated with thrombotic microangiopathy in an adult. Clin Nephrol. 2000;54: 169-73.
pmid
23. Izumi T, Hyodo T, Kikuchi Y, Imakiire T, Ikenoue T, Suzuki S, et al. An adult with acute poststreptococcal glomerulonephritis complicated by hemolytic uremic syndrome and nephrotic syndrome. Am J Kidney Dis. 2005;46: e59-63.
crossref
24. Kakajiwala A, Bhatti T, Kaplan BS, Ruebner RL, Copelovitch L. Post-streptococcal glomerulonephritis associated with atypical hemolytic uremic syndrome: to treat or not to treat with eculizumab? Clin Kidney J. 2016;9: 90-6.
crossref pmid pmc
25. Blumberg RW, Feldman DB. Observations on acute glomerulonephritis associated with impetigo. J Pediatr. 1962;60: 677-85.
crossref pmid
26. Kandall S, Edelmann CM, Jr., Bernstein J. Acute poststreptococcal glomerulonephritis. A case with minimal urinary abnormalities. Am J Dis Child. 1969;118: 426-30.
crossref pmid
27. Fujinaga S, Ohtomo Y, Umino D, Mochizuki H, Takemoto M, Shimizu T, et al. Pulmonary edema in a boy with biopsy-proven poststreptococcal glomerulonephritis without urinary abnormalities. Pediatr Nephrol. 2007;22: 154-5.
crossref pmid
28. Watanabe T, Yoshizawa N. Recurrence of acute poststreptococcal glomerulonephritis. Pediatr Nephrol. 2001;16: 598-600.
crossref pmid
29. Kim P, Park SH, Deung YK, Choi IJ. Second attack of acute poststreptococcal glomerulonephritis; report of two cases. Yonsei Med J. 1979;20: 61-8.
crossref pmid
30. Casquero A, Ramos A, Barat A, Mampaso F, Caramelo C, Egido J, et al. Recurrent acute postinfectious glomerulonephritis. Clin Nephrol. 2006;66: 51-3.
crossref pmid
31. Eison TM1, Ault BH, Jones DP, Chesney RW, Wyatt RJ. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. Pediatr Nephrol. 2011;26: 165-80.
crossref pmid
32. Yap HK, Chia KS, Murugasu B, Saw AH, Tay JS, Ikshuvanam M, et al. Acute glomerulonephritis--changing patterns in Singapore children. Pediatr Nephrol. 1990;4: 482-4.
crossref pmid
33. Zhang Y, Shen Y, Feld LG, Stapleton FB. Changing pattern of glomerular disease in Beijing Children’s Hospital. Clin Pediatr. 1994;33: 542-7.
crossref
34. Ilyas M, Tolaymat A. Changing epidemiology of acute poststreptococcal glomerulonephritis in Northeast Florida: a comparative study. Pediatr Nephrol. 2008;23: 1101-6.
crossref pmid
35. Markowitz M. Changing epidemiology of group A streptococcal infections. Pediatr Infect Dis J. 1994;13: 557-60.
crossref pmid
36. Koo SE, Hahn HW, Park YS. A clinical study of acute poststreptococcal glomerulonephritis in children, from 1994 to 2003. Korean J Pediatr. 2005;48: 606-13.

37. White AV, Hoy WE, McCredie DA. Childhood post-streptococcal glomerulonephritis as a risk factor for chronic renal disease in later life. Med J Aust. 174: 492-6.

38. Berríos X1, Lagomarsino E, Solar E, Sandoval G, Guzmán B, Riedel I. Post-streptococcal acute glomerulonephritis in Chile--20 years of experience. Pediatr Nephrol. 2004;19: 306-12.
crossref pmid
39. Kanjanabuch T1, Kittikowit W, Eiam-Ong S. An update on acute postinfectious glomerulonephritis worldwide. Nat Rev Nephrol. 2009;5: 259-69.
crossref pmid
40. Nast CC. Infection-related glomerulonephritis: changing demographics and outcomes. Adv Chronic Kidney Dis. 2012;19: 68-75.
crossref pmid
41. Stratta P, Segoloni GP, Canavese C, Sandri L, Mazzucco G, Roccatello D, et al. Incidence of biopsy-proven primary glomerulonephritis in an Italian province. Am J Kidney Dis. 1996;27: 631-9.
crossref pmid
42. Nasr SH, Radhakrishnan J, D'Agati VD. Bacterial infection-related glomerulonephritis in adults. Kidney Int. 2013;83: 792-803.
crossref pmid
43. Nasr SH, Fidler ME, Valeri AM, Cornell LD, Sethi S, Zoller A, et al. Postinfectious glomerulonephritis in the elderly. J Am Soc Nephrol. 2011;22: 187-95.
crossref pmid
44. Nasr SH, D’Agati VD. IgA dominant postinfectious glomerulonephritis: a new twist on an old disease. Nephron Clin Pract. 2011;119: c18-c26.
crossref
Editorial Office
Room 103, 124, Bukbyeonjung-ro, Gimpo-si, Gyeonggi-do 10098, Republic of Korea
TEL : +82-31-987-5963   FAX : +82-31-987-5967   E-mail : ckdeditor@kspn.org

Copyright© Korean Society of Pediatric Nephrology. All rights reserved.                powerd by m2community
About |  Browse Articles |  Current Issue |  For Authors and Reviewers