Delayed diagnosis of post-streptococcal glomerulonephritis
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To the Editor:
We read with interest the recent article by Pais et al1 concerning a delay in the diagnosis of poststreptococcal glomerulonephritis (PSGN). The authors defined this delay as a period of 24 hours during which the physician did not begin to look for symptoms of PSGN. Possibly they meant clinical suspicion for PSGN, because 24 hours is not a very long time in which to confirm a streptococcal infection. At any rate, the absence of visible hematuria was the main clinical condition associated with this delay.
In our hospital, we reexamined 22 children (13 males, mean age 6.1 ± 2.4 years) with acute glomerulonephritis (AGN) between January 2000 and August 2008. When admitted to the hospital, 16 of these children were quickly suspected of having AGN. Of these, 11 had visible hematuria, 5 had microhematuria, and 8 had proteinuria detected by deep-stick testing. Five of the children exhibited edema at admission. Ten children had a history of sore throat. Four children exhibited other foci of infection; 8 children had no infection. In contrast, 6 children with hematuria (5 of whom had macrohematuria) were not promptly identified (27%); the diagnosis at admission was urinary tract infection (UTI) in 5 of these children and pneumonia in 1 child. The delay in clinical suspicion ranged from 1 to 2 days. At discharge, 20 patients had AGN. They all had a positive antistreptolysin O titer, positive throat culture, and/or anti-DNAse B titer, but low C3. Two patients who had a clinical history of sore throat and macrohematuria at admission had negative culture and serum titer results and normal C3, and were diagnosed with PSGN. One patient was treated with ramipril and 1 was treated with amlodipin in the acute phase, and 1 patient with prolonged disease was treated with steroids and ramipril. All of these patients had received a timely diagnosis of AGN.
Some delayed diagnosis occurred in our setting as well, even in children with macrohematuria. Many patients with a correct diagnosis at admission had a sore throat. Urinalysis with deep-stick testing was a good initial diagnostic test. UTI may be an uncorrected diagnosis in some children with microhematuria or macrohematuria. Obviously, laboratory confirmation of acute PSGN requires specific diagnostic tools; thus, it is surprising that none of our patients exhibited adverse events. The roles of current treatment practice, timely diagnosis, and individual patient characteristics, particularly young age, have been discussed previously.2
References
PII: S0022-3476(08)01144-X
doi:10.1016/j.jpeds.2008.12.040
© 2009 Mosby, Inc. All rights reserved.
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