T h e ] o u r n a l of P E D I A T R I C S 525

Acute glomerulon@britis m'thout

abnormality of the urine
A case is presented of a 12-year-old girl with many clinical and laboratory findings
strongly suggestive o[ acute glomerulonephritis but with no abnormalities in the urine.
The diagnosis was confirmed by renal biopsy. Type 3, group A fl-hemolytic
streptococdus was isolated # o m a throat culture and bactericidal tests suggested the
presence in significant titer o[ homologous type 3 antibody in her serum.

Morris S. Albert, M.D.,* J o a n M. Leemlng, M.B., Ch.B., and

Peter R. Scaglione, M.D.

NEW YORK, N. Y.

T~E OCCURRENCE of acute glomer- April 23, 1964, with the chief complaint of
ulonephritis without abnormalities in the swelling of the eyes for one week. Three weeks
urine has been reported by several authors. prior to admission, the patient developed chills,
However, before the a d v e n t o f the percutane- a mild sore throat, and pains in the hands and
feet which cleared without treatment. The week
ous renal biopsy technique, this entity was
prior to admission the child complained of head-
difficult to verify. T h r e e recent case re-
aches and became listless. Edema, initially of
ports 1, 2 which included histologic studies of periorbital distribution, became generalized 2
renal tissue obtained by percutaneous renal days before admission. The patient noted that
biopsy have confirmed earlier impressions she was voiding less frequently than usual but
that this entity does exist. T h e present case observed no change in the appearance of the
represents one of the few patients observed urine.
in the pediatric age g r o u p ? I n this patient The child had been hospitalized previously in
the acute nephritis occurred in conjunction February, 1963, for evaluation of psychomotor
with a type 3, group A /?-hemolytic strepto- seizures of 2y~ years' duration. At that time the
coccal infection. blood pressure was 110/80 mm. Hg, and physical
examination was normal. Urinalysis, sedimenta-
CASE REPORT tion rate, serum nonprotein nitrogen, and chest
x-ray were normal. The electroencephalogram
D. L., a 10I/.o-year-old Negro girl, was ad-
was "mildly abnormal." The seizures were con-
mitted to The Babies Hospital in New York on
trolled with Dilantin, Mysoline, and Dexedrine.
From the Department o[ Pediatrics, College o[ Physical examination revealed a well-nourished
Physicians and Surgeons, Columbia University, Negro girl with periorbital and minimal pretibial
and The Babies Hospital, New York. edema. The temperature was 99.2 ~ F.; pulse, 58
Supported in part by a grant from the Kidney per minute; respiration, 32 per minute; and
Disease Foundation o[ New York, and by a blood pressure, 172/100 ram. Hg. She weighed
Public Health Service Fellowship (5-F2-HE20,
281-02) from the National Heart Institute. 41.6 kilograms and measured 150 cm. The optic
*Address, 630 West 168th Street, New York, N. Y. 10032. fundi demonstrated arteriolar narrowing but no
 526 Albert, Leeming, and Scaglione April 1966

hemorrhages or exudate. The tonsils were large; pelvis. The collecting systems, somewhat ob-
the heart and lungs, normal. The abdomen was scured on the right by the bony structures of
flat and a smooth nontender liver edge was the pelvis, appeared to be normal in size and
palpable at the right costal margin. Neurologic shape. A cinecystogram outlined a normal blad-
examination was within physiologic limits. der and urethra, and there was no ureteral reflux.
The hemoglobin level was 9.5 Gm. per cent; Bactericidal tests for detection of type 3 anti-
the white blood cell count 7,200 per cubic milli- body in the patient's serum were carried out.
meter with a normal differential; the erythrocyte Acute phase serum showed a titer of 1:40 which
sedimentation rate was 77 mm. in one hour dropped to 1:5 6 months later. Thus, there was
(Westergren). The clear, amber-colored urine a 6 to 8 fold decrease in the titer which is con-
had a specific gravity of 1.010, was free of pro- sidered to be a significant change. It is con-
tein, and contained 2 to 4 white blood cells, and cluded from these studies that the patient had
no red blood cells per high power field of cen- had a type 3 streptococcal infection prior to the
trifuged sediment. The nonprotein nitrogen was time when the first specimen of serum was ob-
18 mg. per cent; the serum albumin 3.9 Gm. per tained. Since a rise in titer was not demonstrated,
cent; and the serum globulin 4.1 Gm. per cent one cannot be certain that the infection was of
with a gamma globulin of 2.1 Gin. per cent (nor- recent origin, but this is strongly suggested by
mal: 0.91 to 1.25 Gm. per cent). On admission, the isolation of type 3, group A fl-hemolytic
the antistreptolysin titer was 1,250 Todd units. streptococcus from the throat culture at the time
The electrocardiogram was within normal limits of admission to the hospital, and the subsequent
for the age. The electroencephalogram was un- relatively rapid decrease in antibody titer.
changed from the previous record. Course. One hour following a single intramus-
Culture of the throat at the time of admission cular dose of reserpine (2.0 mg.), the patient be-
grew type 3, group A fl-hemolytic streptococcus. came normotensive. Over a period of 2 days she
Culture of the urine was sterile. A chest x-ray lost 3.8 kilograms in weight, became edema-free,
revealed moderate enlargement of the heart, in- and the initial lassitude cleared. In addition to
creased pulmonary interstitial markings, inter- the continuation of anticonvulsant medications,
lobar fluid, and bilateral pleural effusions. The she received procaine penicillin, 600,000 units
intravenous pyeIogram demonstrated prompt intramuscularly for 10 days. Throughout the hos-
function bilaterally. The left kidney was normal pital stay, and subsequently, repeated urinalyses,
in position; the right kidney was located in the Addis counts, and quantitative determinations

T a b l e I. Course an d l a b o r a t o r y findings of P a t i e n t D. L.

Date Weight Blood pressure Erythroeyte(ram(.westergren)SedimentatiO1ninhr.) rate Nonprotein nitrogen

1964 (kilograms) (ram. Hg.) (me. %)
4/23 190/110 70 18
4/23 41.6 172/100 37
4/24 41.0 132/88
4/25 39.5 120/78 58 28
4/26 37.8 108/50
4/27 37.8 100/40 36
4/28 37.8 115/74
4/30 38.1 102/64 30
4/29 37.9 100/70
4/30 42
5/ 1" 38.2 100/60 47
5/ 2 38.1 110/70 30 28
5/ 4 38.6 110/74 22
5/ 5 39.2 108/70
5/ 6 38.9
5/25 41.5 120/80 26
7/ 6 43 105/80 23 25
9/21 120/70 17 27
*Renal biopsy.
tOcc., occasional.
 Volume 68 Number 4 Acute gIomeruIonephritis 527

of urine protein remained within normal limits and by the reports of Wertheim and associ-
(Table I). On May 1, 1964, a percutaneous ates, ~ several types of streptococci have been
biopsy of the left kidney was performed. The associated with acute gIomerulonephritis,
specimen, which contained about 40 glomeruli, including type 3.
showed hypercellularity and thickening of the I n addition to the fact that only certain
basement membranes of all glomeruli (Fig. 1).
specific types of streptococci have been found
The tubules and interstitial tissues were normal.
in association with acute nephritis, there ap-
The findings were compatible with a diagnosis
of acute proliferative glomerulonephritis. pears to be evidence that individual strains
of these streptococcal types may vary in their
DISCUSSION capacity to induce this disease. This varia-
T h e course of this child's illness, the tion has been suggested by the large fluctua-
laboratory and histologic findings are strongly tion in the incidence of acute nephritis fol-
suggestive of poststreptococcal acute glomer- lowing epidemics of type 126; it m a y also be
ulonephritis, except for the fact that the a factor in the attack rate of acute nephritis
urine was consistently normal. A transient following type 3 infections. However, apart
abnormality of the urine m a y have oc- from strain differences, variation in host re-
curred in the interval between the onset of sponse is probably a further factor affecting
illness and admission to hospital but seems the severity of nephritis.
unlikely. At the present time there is little informa-
Particularly noteworthy in this patient was tion on the relationship between the strepto-
the recovery o5 type 3, group A fl-hemolytic coccal type or strain and the clinical or labora-
streptococcus from the throat and the signif- tory manifestations of the resuItant nephritis.
icant liter of homologous antibody in the T h e frequency with which hemolytic strepto-
serum. T h e studies of R a m m e l k a m p and cocci are isolated in cultures of the throat
Weaver 4 showed that type 12 was most com- from patients With acute nephritis has
monly found in association with acute glo- diminished since the advent of antibiotics and
merulonephritis. However, as is emphasized their frequent use in the treatment of upper
by their study and review of the literature, respiratory infections. Furthermore, facilities

Urinalysis Addis count (12 hours)

Specific White blood Red blood mOsm./Kg. Red blood White blood Protein
pH gravity Protein cells cells HeO cells cells (Gm.)
1.010 0 Rare --
7.5 1.010 Faint trace 2-4 --
6.5 1.015 Trace 2-4 Rare
7.5 1.019 Trace 2-4 --
Acid 1.020 0 Rare
566 80,000 40,000 0.004
6.5 1.025 Trace 3-6 Rare (1 hyaline cast)
7.0 1.018 Trace 2-4 Rare
6.0 1.018 Trace Occ.t
6.5 1.016 0 Rare
7.0 1.029 Trace ~ 782 440,000 80,000 0.007
7.5 1.024 Trace 3-6 2-4
6.0 1.006 0 0-2
5.5 1.011 Faint trace -- 5-10
975 360,000 40,000 0.005
1.012 0 Occ.t
1.015 0 --
1.012 0 Occ.t 874 80,000 80,000 0.019
5 28 Albert, Leeming, and Scaglione April 1966

Fig. 1. Photomicrograph of a representative glomerulus from renal biopsy. This glomerulus

shows marked hypercellularity with moderate, multifocal thickening of the basement membrane.
(Hematoxylin and eosin. Original magnification x603.)

for typing streptococci and the determina- Rebecca C. Lancefield of the Rockefeller Insti-
tion of type specific antibodies in the blood tute, New York, New York.
are not generally available. Thus, variations The renal biopsy specimen was interpreted by
in the clinical picture of acute nephritis as- Dr. William A. Blanc, Associate Professor of
sociated with streptococcal infection are dif- Pathology, College of Physicians and Surgeons,
Columbia University.
ficult to study, particularly in sporadic cases
such as the patient without urinary abnor- REFERENCES
mality described in this paper.
1. Berman, L. B., and Vogelsury, P.: Poststrepto-
The streptococcal typing was performed by coceal glomerulonephritis without proteinuria,
the courtesy of Dr. Stanley H. Bernstein, Direc- New England J. Med. 268" 1275, 1963.
tor of the Streptococcal Unit, Long Island Jewish 2. Cohen, J. A., and Levitt, M. D." Acute glo-
merulonephritis with few urinary abnormalities:
Hospital, New Hyde Park, New York. Report of two cases proved by renal biopsy,
Tests for streptococcal antibodies were kindly New England J. Med. 268: 749, 1963.
carried out by Dr. John B. Zabriskie and Dr. 3. Blumberg, R. W., and Feldman, D. B.: Ob-
Volume 68 Number 4 Acute glomerulonephritis 529

servations on acute glomerulonephritis asso- The association of type specific hemolytic

ciated with impetigo, J. P~DIAT. 60: 677, 1962. streptococci with acute glomerulonephritis, J.
4:. Rammelkamp, C. H., and Weaver, R. S.: Acute Clin. Invest. 32: 359, 1953.
glomerulonephritis. The significance of the Schwartz, W. B., and Kassirer, J. P. : Clinical
variation in the incidence of the disease, J. aspects of acute glomerulonephritis, in Strauss,
Clin. Invest. 39: 345, 1953. W. B., and Welt, L. G., editors: Diseases of
5. Wertheim, A. R., Lyttle, J. D., Loeb, E. N., the kidney, Boston, 1963, Little, Brown & Co.,
Earle, D. P., Seegal, B. D., and Seegal, D.: p. 268.