eMedicine Specialties > Nephrology > Glomerular Diseases

Glomerulonephritis, Nonstreptococcal Associated With Infection: Differential Diagnoses & Workup

Author: James W Lohr, MD, Fellowship Program Director, Professor, Department of Internal Medicine, Division of Nephrology, State University of New York at Buffalo
Coauthor(s): Quresh T Khairullah, MBBS, Consulting Staff, Department of Medicine, Division of Nephrology, St John's Hospital and Medical Center
Contributor Information and Disclosures

Updated: Dec 15, 2008

Differential Diagnoses

Glomerulonephritis, Membranoproliferative
Hemolytic-Uremic Syndrome
IgA Nephropathy
Nephritis, Lupus
Serum Sickness

Other Problems to Be Considered

Type 1 membranoproliferative GN other than that due to infectious causes
Mixed cryoglobulinemia
Atheroembolic disease and hemolytic uremic syndrome: These are examples of nonimmune complex–mediated diseases that may mimic GN.

Workup

Laboratory Studies

• Urinalysis: This may reveal hematuria, pyuria, red blood cell casts, and proteinuria. Findings are very helpful for determining if glomerulonephritis (GN) is primarily of a nephrotic or nephritic type.
• CBC count: The neutrophil count may be elevated in patients with an acute bacterial infection. Eosinophilia may be observed in patients with GN associated with SBE or a parasitic infection. Depending on the duration of disease and severity of renal dysfunction, anemia may be observed due to chronic kidney disease.
• BUN and creatinine: BUN and serum creatinine levels are commonly elevated in patients with infection-related GN. However, levels may be normal early in the course of these disorders.
• Electrolytes: Hyperkalemia or evidence of metabolic acidosis may be observed if the patient presents with chronic renal insufficiency.
• Liver function tests: The aspartate aminotransferase level is commonly elevated in patients with hepatitis-associated GN.
• Rheumatoid factor: The results commonly are positive in patients with GN associated with bacterial endocarditis.
• Serum complement levels (C3, C4, CH50): Complement levels commonly are low in patients with infection-related GN, more so in those with certain diseases. Low complement levels indicate an immune complex disease and are not necessarily diagnostic because they can be present in patients with other immune complex diseases (eg, lupus nephritis).
• Hepatitis panel (hepatitis B surface antigen, hepatitis C antibody): Hepatitis is a common cause of infection-related GN.
• Cryoglobulins: These are commonly present in patients who have GN associated with hepatitis C.
• VDRL test: Findings are positive in patients with GN associated with syphilis.
• HIV testing: This should be performed on all patients with GN and risk factors for HIV infection.
• Viral titers (cytomegalovirus, parvovirus B19, mumps, varicella, Epstein-Barr virus, Hantavirus): Depending on the clinical presentation, drawing blood for viral titers may be important in order to help identify the cause of the GN.
• Stool for ova and parasites: This should be performed if the patient has been in areas endemic to diseases such as schistosomiasis or filariasis.
• Antistreptolysin-O titer, antineutrophil cytoplasmic antibodies, antiglomerular basement membrane antibody, serum protein electrophoresis, and urine protein electrophoresis: Depending on the clinical presentation, these tests may be performed as part of the evaluation to help identify the cause of the GN.
• Other evaluations: In appropriate clinical circumstances, peripheral blood smears to test for malaria may be helpful.

Imaging Studies

• Renal ultrasound: This is routinely obtained in patients presenting with abnormal renal function to help rule out obstructive causes of nephropathy, and findings demonstrate certain anatomic abnormalities. It is also useful to confirm the presence of 2 functioning kidneys prior to performing percutaneous renal biopsy.
• CT scan of the chest, abdomen, or pelvis: This may be indicated if visceral abscess is suggested.
• Echocardiogram: A transthoracic echocardiogram should be performed if bacterial endocarditis is a possible cause. If findings are inconclusive, a transesophageal echocardiogram is indicated to help rule out valvular vegetations.

Procedures

• Kidney biopsy and other biopsies: These may be helpful depending on the clinical presentation.

Histologic Findings

Depending on the cause, a number of different renal lesions may be seen, as follows:

• Syphilis - Membranous or diffuse proliferative GN
• Hepatitis B - Membranous, membranoproliferative, or mesangial proliferative GN
• Hepatitis C - Membranoproliferative GN (most common), membranous GN (also seen)
• HIV - Focal segmental glomerulosclerosis (classic lesion), membranoproliferative GN or minimal change disease (less common)
• Parvovirus B19 - Focal segmental glomerulosclerosis
• Hantavirus - Mesangial GN
• Schistosomiasis - Mesangial proliferative GN, focal segmental glomerulosclerosis, membranoproliferative GN, or membranous GN
• Leishmaniasis - Mesangial or focal proliferative GN
• Hydatid - Mesangiocapillary GN, membranous GN
• Toxoplasmosis - Mesangioproliferative GN

• Search for CME/CE on This Topic »

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