Morning Report

Wednesday, July 23, 2014

Jennifer Hranilovich, MD
History and Physical
HPI
L.S. is a previously healthy 11 year old female patient
of yours who was seen at Urgent Care in June with
RUQ pain that did not resolve over several hours.
No n/v, no fever.
UA and culture were performed with negative culture
UA showing microscopic hematuria, no protein.
Pain has since resolved.
Seen by you 2 weeks later for vaccines, where you
repeated UA and found persistent microscopic
hematuria without proteinuria.
Returned two weeks later, UA repeated with similar
findings. Never observed gross hematuria.
History and Physical
Past Medical and Surgical History
Term birth, vaginal delivery, pregnancy without
complications.
Pyelonephritis at 18 mos age; mother does not recall
any renal US or VCUG performed at that time, nor
seeing a nephrologist
Otitis media and seizures on multiple occasions in
early childhood, now resolved
One episode acute dystonia (torticollis) at 3yo.
No surgeries
History and Physical
Allergies
Amoxicillin, Zithromax
Medications
No prescription or OTC meds, no vitamins or
supplements
Immunizations
UTD
History and Physical
Family Medical History
Maternal aunt with sponge kidney
Nephrolithiasis and UTIs in MGF, a maternal aunt, a
maternal uncle, and maternal cousins.
No known history of hematuria in parents or siblings
No family history of hearing loss or visual deficits.
Diabetes and HTN in later life in various grandparents
Maternal cousin with epilepsy
Older brother with CP
History and Physical
Social History
Lives with parents and annoying younger
brother. Has a cat and dog, in the home. Is
in the 6
th
grade and plays the saxophone.
ROS:
Occasional HAs, approx. 1x/week.
Not yet had menarche.
No abdominal or back pain before or since
episode in June.
History and Physical
Physical Examination
VS: Wt 39.3 kg (23%ile), Ht 155.7 (46%ile), BMI 16.21 (15%ile)
T 98 F, BP 98/52, HR 73, RR 24
Gen: Shy but cooperative young woman
HEENT: NCAT, MMM, oropharynx wnl
CV: RRR no m/g/r
Pulm: CTAB
Abd: Soft, no TTP, NABS, no HSM, no masses, no CV
tenderness
GU: Tanner III, no blood in introitus or signs of labial irritation
Ext: No deformities, full ROM
Skin: Warm, well-perfused, no rashes or abnormal birthmarks
Neuro: No gross defects of CNs, strength, tone, gate; patellar
reflexes are 2+ bilaterally.

Laboratory Studies
At Urgent Care:
6/3/14:
UA SG 1.025, pH 5, 2+ heme, no protein, no leukocytes, 1+
urobilinogen, 50 RBC, no growth at 48 hours
At your office:
6/16/14:
UA SG 1.010 pH 7.5, 2+ heme, no protein, +/- urobilinogen, 50 RBC
Group A Strep, cx neg at 48h
CBC: WBC 6.1, Hgb 14.1, Hct 40.5, Plt 281
CMP: Na 139, K 3.8, Cl 1.06, CO2 24, BUN 7, Cr 0.5, BG 93, Ca
9.2, Alb 4.3
6/25/14:
UA: SG 1.010, pH 5, 2+ heme, no protein, 1+ leukocytes, 0.2
urobilinogen

Differential
Asymptomatic
isolated microscopic
hematuria
Transient:
Trauma
Fever
Exercise
ID
Adenovirus
Cytitis
Pyelonephritis
Renal:
IgA nephropathy
Alport Syndrome
Thin Basement
Membrane Disease
Post-streptococcal
glomerulonephritis
Hypercalciuria
Interstitial nephritis
(acute or chronic)
Nephrolithiasis


Hematuria: a broader differential
Gross & microscopic hematuria:
Bleeding tumor
Severe injury to GU tract
Hematuria with proteinuria:
MPGN
RPGN
Hematuria with systemic symptoms
Anti-GBM (Goodpasture)
Lupus nephritis
Henoch-Schnlein Purpura


Hematuria
Epidemiology
Population-based studies of school-age kids
show prevalence for microscopic hematuria in
a single urine sample is 3-4%
Goes to 1% for two or more positive samples
Hematuria with proteinuria prevalence rate
less than 0.7%
Work-up
Algorithm for isolated asymptomatic
microscopic hematuria in children.
See algorithm in UpToDate. Unable to include due to copyright restriction.

Laboratory & Other Studies
Urinalysis in Nephrology:
moderate blood, neg protein, microscopy
reveals 30+ RBCs per HPF and some
dysmorphic and small RBCs
C3, C4, ANA: pending
Urine Ca:Cr AM study: pending
Renal Ultrasound
Both kidneys 9.4cm; normal echogenicity; no
stones

Hematuria
Etiology
Most common causes of persistent
microscopic hematuria
Glomerulopathies
Hypercalciuria
Nutcracker syndrome
History-Taking:
IgA nephropathy:
Often a history of gross hematuria right after a URI or
gastroenteritis.
It may then recur periodically but microscopic
hematuria can be present in between episodes of
gross
Alport syndrome:
Classically recessive X-linked, typically seen in
males, with high-frequency sensorineural hearing
loss, ocular abnormalities, eventual renal failure.
Heterozygous carrier-females also can have
hematuria, but do not have progressive renal disease.
Of note, there are AR and AD forms of Alport
History-Taking:
Thin basement membrane disease:
AKA benign familial hematuria, is AD. In many cases, is the
heterozygous form of AR Alport syndrome
Poststreptococcal glomerulonephritis:
Gross hematuria ~2 weeks after strep - microscopic hematuria
can persist 6-12 months after the presentation
Hypercalciuria:
Urine calcium/creatinine ratio >0.2 (mg/mg) in kids > 6yo is
associated with asymptomatic microscopic hematuria. Unclear
relationship to nephrolithiasis
Nutcracker syndrome:
Left renal vein compression between the aorta and proximal
superior mesenteric artery
May be associated with left flank pain
References

Gagnadoux, Marie France. Evaluation of
microscopic hematuria in children.
Up To Date. June 2014.