How urine affects our thought process

Article Outline

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A report in this issue of The Journal by Pais et al seems like a somewhat mundane series of children with post-streptococcal glomerulonephritis (PSGN). Yet, it is really a reminder of the mental processes involved in making diagnoses, and some traps which lead to errors.

The study is an analysis of 17 children with a delay of 24 hours or more between first contact with a physician and establishing the diagnosis of PSGN. The delay was not because physicians were pursuing other glomerular diseases, but rather because they did not recognize that the children had renal disease at all! In most of the missed cases, the child presented with nervous system complaints (eg, headaches, mental status changes, seizures) or shortness of breath/fluid overload. The majority did not have gross hematuria.

Physicians tend to categorize patients based upon history and pursue diagnoses based upon these categorizations. When a child presents with gross hematuria, especially with a preceding history of infection, PSGN is an early fork in the diagnostic road. Without the history of gross hematuria, however, a child coming to the Emergency Department with seizures and altered mental status may find herself subjected to a workup more focused on primary neurologic disease. In such a setting, rather than being seen as a clue to the presence of kidney disease, the finding of hypertension might be ignored or passed over as a consequence of encephalopathy rather than its cause.

The lessons of the work of Pais et al go far beyond the diagnosis of PSGN.