What is the appropriate management for a 7-year-old child presenting with intermittent abdominal pain, recurring infections, generalized edema, hypertension, and tea-colored urine?

Evaluation of a 7-Year-Old with Intermittent Abdominal Pain, Recurrent Infections, Edema, Hypertension, and Tea-Colored Urine

This clinical presentation strongly suggests acute post-streptococcal glomerulonephritis or another form of glomerulonephritis, requiring immediate renal function assessment, urinalysis, and appropriate imaging. 1

Key History Questions

Current Presentation

• Urinary symptoms: Frequency, dysuria, changes in urine volume or color (timing of tea-colored urine)
• Edema characteristics: Onset, progression, location (periorbital, extremities, generalized)
• Blood pressure measurements: Recent readings, any symptoms of hypertension (headache, visual changes)
• Abdominal pain: Location, severity, timing, relation to meals or urination
• Infectious history: Recent streptococcal infection (sore throat, skin infection), timing of recurrent infections

Past Medical History

• Previous episodes: Similar symptoms in the past
• Infection history: Types, frequency, and treatment of recent infections
• Growth parameters: Any growth delays suggesting chronic disease
• Medication history: Current and recent medications
• Family history: Renal disease, hypertension, hearing loss (suggesting Alport syndrome)

Physical Examination Focus

• Vital signs: Blood pressure (compare to age-appropriate norms)
• Growth parameters: Height, weight, BMI percentiles
• General appearance: Distress, pallor, edema
• HEENT: Periorbital edema, pharyngeal erythema
• Cardiovascular: Heart sounds, rate, rhythm
• Pulmonary: Evidence of fluid overload
• Abdominal: Tenderness, masses, hepatosplenomegaly, costovertebral angle tenderness
• Skin: Rashes, lesions (impetigo)
• Extremities: Edema, joint swelling

Initial Laboratory Evaluation

• Urinalysis: Assess for:
  • Proteinuria (quantify with protein/creatinine ratio)
  • Hematuria (RBC morphology, casts)
  • Specific gravity
  • Leukocyte esterase and nitrites
• Urine culture: Rule out UTI
• Complete blood count: Assess for anemia, leukocytosis
• Comprehensive metabolic panel: BUN, creatinine, electrolytes
• Inflammatory markers: ESR, CRP
• Complement levels: C3, C4 (low in post-streptococcal glomerulonephritis)
• ASO titer and anti-DNase B: Evidence of recent streptococcal infection
• Streptococcal culture: If pharyngitis present

Imaging Studies

• Renal ultrasound: First-line imaging to assess kidney size, echogenicity, hydronephrosis 1, 2
• Consider VCUG: If history suggests vesicoureteral reflux or recurrent UTIs 1

Additional Testing Based on Initial Results

• 24-hour urine collection: For protein and creatinine clearance if proteinuria present
• Renal biopsy: Consider if diagnosis remains unclear after initial workup
• Audiogram: If family history suggests Alport syndrome 1

Differential Diagnosis

1. Post-streptococcal glomerulonephritis: Tea-colored urine, edema, hypertension following streptococcal infection
2. Other glomerulonephritides: IgA nephropathy, lupus nephritis, MPGN
3. Nephrotic syndrome: Significant proteinuria, hypoalbuminemia, edema
4. Hemolytic uremic syndrome: Following diarrheal illness
5. Urinary tract infection with pyelonephritis: Recurrent infections with renal involvement 1
6. Vesicoureteral reflux: Recurrent UTIs with potential renal scarring 1
7. Intermittent hydronephrosis: Causing recurrent abdominal pain 3, 4

Management Approach

1. Immediate interventions:

   • Control hypertension if severe (>95th percentile + 5 mmHg)
   • Monitor fluid status and urine output
   • Treat electrolyte abnormalities

2. Disease-specific management:

   • For post-streptococcal glomerulonephritis: Supportive care, blood pressure control
   • For UTI: Appropriate antibiotics based on culture results 1
   • For vesicoureteral reflux: Consider antibiotic prophylaxis 1

3. Follow-up monitoring:

   • Serial blood pressure measurements
   • Repeat urinalysis to monitor resolution
   • Renal function tests
   • Growth parameters

Key Pitfalls to Avoid

• Misdiagnosing as simple abdominal pain: Tea-colored urine with edema and hypertension strongly suggests glomerular disease 1
• Overlooking hypertension: Essential to measure BP accurately using appropriate cuff size
• Inadequate follow-up: Renal function must be monitored even after acute symptoms resolve
• Missing family history: Important for hereditary nephropathies
• Attributing symptoms solely to infection: The constellation of symptoms suggests kidney involvement beyond simple infection 1

Red Flags Requiring Urgent Intervention

• Severe hypertension (>99th percentile + 5 mmHg)
• Oliguria or anuria
• Altered mental status
• Pulmonary edema
• Rapidly worsening renal function

This structured approach will help identify the underlying cause of this concerning presentation and guide appropriate management to prevent long-term renal damage.