Diagnostic Considerations

In the evaluation of a patient with acute glomerulonephritis, if evidence of a previous streptococcal infection is missing or inconclusive, then a search for another infectious cause appears appropriate.

Bacterial and viral infections

The syndrome of acute glomerulonephritis has been reported following many other bacterial illnesses (eg, Streptococcus pneumoniae, Staphylococcus aureus and S epidermidis, Rickettsia rickettsiae, Mycoplasma species, Meningococcus species, Leptospira species). In addition, certain viral illnesses have preceded the onset of fairly typical acute glomerulonephritis; among the most common are varicella-zoster virus (VZV), cytomegalovirus (CMV), and the Epstein-Barr virus (EBV).

IgA-associated glomerulonephritis

Immunoglobulin A (IgA)–associated glomerulonephritis may be confused with acute poststreptococcal glomerulonephritis.^{[4, 18, 43, 56]}In the form of IgA nephropathy associated with a typical anaphylactoid purpura (ie, Henoch-Schönlein purpura nephritis), the characteristic rash and the associated symptoms of either abdominal pain or arthritis and/or arthralgia help in the differentiation; however, in atypical cases, marked similarity may be present.

All of the clinical manifestations of APSGN have been reported in persons with Henoch-Schönlein purpura nephritis, although significant hypertension and edema are found less commonly in individuals with Henoch-Schönlein purpura than in those with APSGN. In addition, evidence of a previous streptococcal illness is usually lacking in individuals with Henoch-Schönlein purpura nephritis, and complement values (C3 and/or C4) are usually normal.

Urticarial or purpuric rashes, abdominal complaints, and arthritis and/or arthralgia are found almost exclusively in persons with Henoch-Schönlein purpura.

Berger disease or IgA nephropathy usually presents as an episode of gross hematuria occurring during the early stages of a respiratory illness; no latent period occurs, and hypertension or edema is uncommon.

Recurrent episodes of gross hematuria, associated with respiratory illnesses, followed by persistent microscopic hematuria, are highly suggestive of IgA nephropathy. In contrast, acute poststreptococcal glomerulonephritis usually does not recur, and second episodes are rare.

MPGN

Mesangiocapillary or membranoproliferative glomerulonephritis (MPGN) may have a presentation that is virtually identical to that of poststreptococcal acute glomerulonephritis. The initial manifestations are often more serious in persons with MPGN than in those with IgA nephropathy; the renal function is reduced markedly (ie, large elevation of serum creatinine).

Evidence of preexisting streptococcal infection is absent, although cases of MPGN have been reported in which clear evidence of such an infection is present. In most cases, C3 levels are depressed persistently, longer than 6 weeks.

Urinary abnormalities persist past the time of expected resolution for acute poststreptococcal glomerulonephritis.

Crescentic glomerulonephritis

Crescentic glomerulonephritis is the term used to describe a histologic picture of severe proliferative glomerulonephritis. In persons with crescentic glomerulonephritis, in addition to inflammatory changes within the glomerular tuft, extensive proliferation exists within the Bowman space, leading to the formation of synechiae between the glomerular tuft and Bowman capsule.^[43]

The clinical picture is generally referred to as rapidly progressive glomerulonephritis and may be secondary to numerous causes, including an immune-complex mediated poststreptococcal nephritis. The initial clinical picture is generally severe, and resolution appears delayed.

Other types of glomerulonephritis

Other forms of glomerulonephritis (eg, systemic lupus erythematosus nephritis, familial nephritis, chronic glomerulonephritis) may occasionally be confused with acute poststreptococcal glomerulonephritis when an acute exacerbation of the previously present nephropathy is present. In addition to the lack of expected complete resolution, other features suggest a condition other than acute poststreptococcal glomerulonephritis.

See Hemolytic Complement under Workup for the differential diagnosis of acute glomerulonephritis according to C3 levels.

Differential Diagnoses

Crescentic Glomerulonephritis
Diffuse Proliferative Glomerulonephritis
Endocarditis-associated glomerulonephritis
Hematuria
IgA Nephropathy
Membranoproliferative Glomerulonephritis
Pediatric Nephritis
Shunt nephritis

Workup

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Media Gallery

Schematic representation of proposed mechanisms involved in the development of acute poststreptococcal glomerulonephritis (APSGN).MES: mesangial cell; END: endothelial cell; PMN: polymorphonuclear cell; MΦ: macrophage; T: T lymphocyte; GMB: glomerular basement membrane; C: complement; Anti-NAPlr-Ab: Anti-NAPlr-antibody. Courtesy of open access article, "The Role of Nephritis-Associated Plasmin Receptor (NAPlr) in Glomerulonephritis Associated with Streptococcal Infection." Oda T, Yoshizawa N, Yamakami K, et al. Journal of Biomedicine and Biotechnology, 2012; doi: 10.1155/417675.

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