PNEUMONIA-ASSOCIATED ACUTE GLOMERULONEPHRITIS IN A NIGERIAN ADOLESCENT.

Abstract

Summary/introduction: Acute Glomerulonephritis (AGN) is one of the most common childhood renal diseases in Nigeria. Acute Post-infectious glomerulonephritis (APIGN)-typified by post-streptococcal AGN (PSGN)-is the commonest, usually developing 1-6 weeks after an infectious episode. Rarely, AGN may occur concurrently with the inciting infectious process and may go unnoticed by clinicians. An example is pneumonia-associated AGN with isolated cases documented in Israel, the USA, and Europe but none to our knowledge from a Nigerian and perhaps the African population. This article reports a 17-year-old Nigerian male adolescent who developed AGN during an episode of complicated left lobar pneumonia.

Case report: A 17-year-old male adolescent presented with fever, left-sided chest pain, cough and progressive dyspnoea. There was no current or remote history of sore throat, skin rashes or urinary symptoms and past medical history was unremarkable. He is a paternal orphan and engages in subsistence farming with his mother. Examination revealed respiratory distress, pyrexia(38.9oC), BMI of 15Kg/M2(<-3SD, WHO, BMI-for-age/sex), stony-dull percussion notes over the left hemithorax, no oedema, and BP=100/60mmHg. Chest radiographs confirmed massive effusion with underlying left upper lobe consolidation. An immediate thoracostomy confirmed empyema thoracic, which initially did not grow pathogens. Initial management focused on empyema drainage and antibiotic coverage using intravenous amoxicillin-clavulanate but response was marginal. By the 5th day, he developed generalized oedema, oliguria, haematuria (+3), hypertension (140/90mmHg, >95thpercentile), congestive cardiac failure, and isolated C3 hypocomplementaemia (C3=60.3{80-160}mg/dL; C4=21.6{15-48}mg/dL). A repeat pleural fluid culture yielded Coliform species (not differentiated/identified because of resource constraints in our laboratory at this time) sensitive to ciprofloxacin but resisted amoxicillin clavulanate. He was subsequently treated with furosemide, amlodipine, and ciprofloxacin with complete resolution of the symptoms (except haematuria), and discharged on the 30 day. At 6-month follow-up, he remained normotensive with resolved haematuria; and normalized C3 complement (120{80-160}mg/dL).

Conclusion: Children with pneumonia who develop features of impaired renal function should be investigated for AGN. This report highlights this rare and unusual association as a possibility in our setting; and also brought up the difficulties with diagnostic procedures in resource constrained settings like ours, especially in light of widespread antimicrobial resistance and rational antibiotics use.