A Child with Post-streptococcal Acute Glomerulonephritis Complicated by Coombs Positive Autoimmune Hemolytic Anemia

摘要

The simultaneous occurrence of acute post-streptococcal glomerulonephritis (PSAGN) and autoimmune hemolytic anemia (AIHA) is rare. A 5-year-old African-American boy was admitted with acute renal failure, hematuria, nephrotic syndrome and severe hemolytic anemia. The patient also had a low serum level of complement 3 (C3) and elevated anti-streptolysin O (ASO) titer. Kidney biopsy confirmed post-infectious glomerulonephritis with diffuse hypercellularity, sub-endothelial and sub-epithelial deposits. The patient received three blood transfusions and his hematocrit became stable without the necessity of steroid treatment. Renal function rapidly improved and his serum level of C3 returned to normal within two months and his proteinuria disappeared in 4 months. This case illustrates the rare occurrence of severe AIHA in association with PSAGN. This association suggests a potential role of anti-streptolysin O in the pathogenesis of the hemolytic anemia. Case A 5-year-old African-American boy was referred to the Le Bonheur Children's Medical Center emergency department for acute onset of anemia. He was initially seen by his primary care physician four days prior to admission with headache, runny nose, cough and occasional vomiting. He denied sore throat and Streptococcal screening was negative. He was diagnosed with a viral infection and started on symptomatic treatment with acetaminophen. He had on and off fever up to 102°C for the following four days and was noticed by his parents to have increasing fatigue and a decrease in both oral intake and urine output. He was seen again by his primary care physician on the day of admission. He appeared pale and his hematocrit at the office was 14%. He denied any history of unexplained bruising, gross hematuria or blood in the stool. Past medical history was unremarkable and history was negative for sick contacts, insect bite and travel. He did not have sickle cell disease or any previous history suggestive of thalassemia. On physical examination, his body weight was 26.4 kg (95 %) and his height was 122.7 cm (95 %). His body temperature was normal at 37°C. He had tachycardia with heart rate of 123 per minute, and his respiratory rate was 24 per minute. His blood pressure was 111/68 mm Hg (95% for age and height was 117/76 mmHg). He was pale and had peri-orbital and pedal edema and abdominal distension suggestive of ascites. He had no icterus or splenomegaly, and the rest of his systemic examination was unremarkable. His admission laboratory results are depicted in Table One.