Pediatric emergency medicine trisk 2896 2896
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Serologic testing to document recent streptococcal infection is helpful but
does not prove causation, as a significant number of children are
asymptomatic carriers. Serologic tests available include titers for
antistreptolysin
O
(ASO),
antihyaluronidase,
antistreptokinase,
antinicotinamide-adenine dinucleotidase, and anti-DNAse B. ASO may be
negative in the setting of streptococcal cellulitis, and it is important to note
that antibiotic therapy may blunt the increase in antibody titers.
The urine sediment will demonstrate glomerular erythrocytes and
leukocytes, and may contain red cell casts. Proteinuria is not uncommon,
though not typically in the nephrotic range.
Renal biopsy is generally not indicated for the diagnosis of APSGN. It
may be considered if the clinical picture does not clearly support a
diagnosis of APSGN, if renal function does not recover in an expected
fashion, or if C3 levels remain persistently low.
Clinical management. Therapy for APSGN is largely supportive although
antibiotics should be initiated if active infection is still present. Given the
underlying glomerular inflammation and generally intact tubular function,
there is a propensity for salt and water retention leading to edema and
increased blood pressure. Therefore, weight should be measured daily and
blood pressure checked regularly during the early acute illness. Children
with hypertension or decreased renal function should be considered for
admission. If edema or hypertension is present, salt and fluid restriction
should be initiated and diuretic therapy considered. Furosemide can be
provided at doses of 0.5 to 1 mg/kg once to four times daily to optimize
fluid balance. If the child is hypertensive, short- or long-acting calcium
channel blockers can be initiated while awaiting recovery. If the blood
pressure is significantly elevated, IV hydralazine 0.1 mg/kg can be given
every 4 to 6 hours with appropriate dose adjustment until other supportive
measures are effective. If a child demonstrates persistent hypertension and
proteinuria and if renal function has been stable, ACE inhibitors can be
considered with close monitoring of serum creatinine and potassium.
The prognosis for complete recovery from the initial episode of APSGN
is good, even for those who presented with renal insufficiency or
hypertension. Generally, the clinical symptoms of APSGN begin to improve
after 1 to 2 weeks. If reduced renal function and edema are evident at
presentation, renal function begins to normalize and diuresis ensues within
