Diagnostic Dilemma

Cola coloured urine with persistent low C3

A 2 year old girl presented with fever for 7 days and cola colored urine for 1 day. There was no oliguria, edema or vomiting. There was no history of any drug ingestion. On examination, blood pressure was normal. Other examination findings were normal. Investigations showed:
• Urine = 30-40 RBCs/hpf, Albumin – 2+, No pus cells. A repeat urine after 7 days was normal.
• Urine culture = No growth
• BUN, creatinine = Normal
• USG Abdomen = Normal
• ASLO = Negative
• Urine calcium/creatinine = 0.1
• C3 = 65 mg/dl (Normal = 110 to 120 mg/dl). Repeat C3 after 6 weeks = 90 mg/dl

What is the likely diagnosis?
Expert Opinion :
This child had glomerular cause of hematuria (in view of trace albuminuria and cola coloured urine). Since the child had fever, the most common cause would be post infectious acute glomerulonephritis (AGN) of which streptococcal infection would be commonest followed by other viral infections. C3 levels usually decrease which may normalize by 6 weeks but occasionally may take 12-24 weeks to normalize. The child’s hematuria has now disappeared and there is no history of any drug intake ruling out drug induced hematuria. The child did have a low C3 which though showed an increasing trend by 6 weeks was still not normal. Thus, a repeat C3 after another 6 weeks is warranted. Persistently low C3 would make one suspicious of other differential diagnosis such as MPGN or SLE in which case urine abnormalities would have persisted. Regarding the ASLO, the infection could have been viral. Also streptococcal diagnosis is made more reliably by antistreptozyme test rather than ASLO test. Thus, to prove streptococcal infection, one needs to do antistreptozyme test as ASLO may still be negative. In this child, C3 was normal after 12 weeks, though antistreptozyme test was negative. Thus diagnosis was post infectious acute glomerulonephritis (infection most probably was viral).
Answer Discussion :
Ibrahim Mitwally
IgA nephropathy
1 year ago
Collins Adjei
Urinary tract infection
1 year ago

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