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Monday, August 24, 2015

A 4 Year Old Girl Is Admitted In Pediatric Ward With The Chief Complaint Of Generalized Body Swelling

A 4 year old girl was admitted to the pediatric ward with the chief complains of generalized body swelling. He mother gives the history that she noticed the swelling first appearing on the face about 5 days ago which then gradually progressed to involve the entire body. The patient has decreased appetite and has lost interest in playing with her toys. Mother also mentions that the patient has only passed urine once yesterday and it was very small in quantity.Urine was dark colored but she did not see any blood in urine.  Before the onset of theses symptoms , the child was in good health except for a minor upper respiratory infection about a week ago. Before the illness the child was taking regular food cooked at home that included boiled eggs, vegetables and sometimes meat. She was immunized and her development was appropriate for her age.
On Examination she had a fever of 101 F. other vitals were within normal limits.
On general physical examination patient had a periorbital edema, puffy face, pedal edema and looked lethargic. There was no jaundice but she looked pale.
On abdominal examination she had ascites.
On auscultation of the chest there were some basal crepitations.

List the Differential Diagnosis of the above case:


1. Nephrotic Syndrome:
 Edema starts in face, arms and then descends. Periorbital edema is classical.
 Edema is usually noticed in morning; pitting edema
 History of previous renal disease may or may not be elicited
 Presence of proteinuria, hypoproteinemia and hypercholesterolemia on lab results will confirm the diagnosis.

2. Acute Nephritic Syndrome

3. Congestive Cardiac Failure.

4. Cirrhosis of Liver.

5. Anemia with Hypoproteinemia.

6. Myxedema.

What Investigations will you order for this patient?

1. Urine—for Proteinuria  by dipstick
2. Urine (24 hours)—Albumin > 1 gm/m2 (nephrotic syndrome)
3.  Urine (24 hours)—Urine Protein/Urine Creatinine ratio: Best performed on first morning voided urine sample. Ratios < 0.5 in children younger than 2 years of age and < 0.2in children more than 2 years of age sugges tnormal protein excretion. A ratio > 3 suggests nephrotic range proteinuria.
4.  Serum cholesterol and LDL—Elevated
5.  Serum albumin— < 3 gm/dl (Normal level is 3.5-5.5 gm/dL)
6.  Serum globulin—Normal, although α2 and β globulin are elevated
7.  Urine culture  to rule out Urinary tract infection
8.  Kidney function test—is usually normal but may be deranged in renal failure
9. Serum electrolytes
10. Complete blood count and ESR
11. Mantoux test—To rule out tuberculosis before starting steroids as steroids can flare up Tuberculosis
12.  Chest X-ray —To look for pleural effusion or pulmonary tuberculosis
13.  Ultrasound  abdomen—For kidney size or any organicpathology
14.  C3 levels— Serum C3 levels is determined in all patients of suspected acute glomerulonephritis because a low level narrows a differential diagnosis to certain forms of
glomerulonephritis like post-streptococcal, lupus, membranoproliferative glomerulonephritis
and chronic infection.
15. A kidney biopsy may be needed if symptoms do not improve with treatment.

Final Diagnosis: The patient is most probably suffering from minimal change nephrotic syndrome.

 How will you treat this patient?
1. Steroids: Oral prednisolone is started in a dosage of 2 mg/ kg/day (60 mg/m2/day). The total daily dose is usually split into two or three doses and given daily for 6 weeks.
For maintenance therapy prednisolone is given at ~1.5 mg/kg/day (40 mg/m2/day) given on alternate days, as a single morning dose, for a 6-week period after which it is discontinued.
2. An antacid preparation may be given with prednisolone to reduce gastric irritation.
3, A protein rich diet with no added salt is given.
4. In cases of severe edema fluid intake should be restricted.
5. diuretics may be needed if patient develops respiratory distress.

Some Important Definitions Related to Nephrotic Syndrome in Children:

1. Nephrotic syndrome: Clinical state characterized by proteinuria, hypoalbuminemia, edema and Hypercholesterolemia.

2. Hypoalbuminemia:
 Serum albumin < 2.5 gm%
 Edema appears when serum albumin < 2 gm%
 With serum albumin < 1.5 gm%: Pleural and pericardial effusion appear.

3. Hypercholestrolemia: Serum cholesterol > 250 mg%

4. Remission: Urine albumin nil or trace (or proteinuria < 4 mg/m2/hour) for 3 consecutive days.

5. Relapse: Urine albumin 3+ or 4+ (or proteinuria > 40 mg/m2/hour) for 3 consecutive days, having
been in remission previously.

6. Frequent relapses: Two or more relapses in six months of initial response, or more than three
relapses in any twelve months.

7. Steroid dependence: Two consecutive relapses when on alternate day steroids or within 14 days
of its discontinuation.

8. Steroid resistance: Absence of remission despite therapy with 4 weeks of daily prednisolone in a
dose of 2 mg/kg per day.

2 comments:

  1. Hello, my name is Betty. i was diagnosed of HIV virus 4 years back. Before then, i was dating this Derrick guy. we had something great going on. Our love life only lasted for 8 months. the sixth and seven month of our relationship, i began feeling very weak every now and then. But i never suspected anything until I kept on experiencing different symptoms like having sore throats, constant headache, body weakness e.t.c. I decided to go for a medical check up. I was tested HIV positive. when the doctor broke the news to me, it was as if my whole world had crumbled. it dawned on me then that Derrick has been lying to me. i was very mad to an extent i almost committed suicide. But there was nothing i could do, other than weep and weep. ever since then, i have been spending heavily on medications, going from one medical clinic or the other so I can look healthy. Though since i was a kid, i love herbs a lot. i take herbal tea with grandma while growing so i am quite familiar with herbs. early last year, i was on the internet and on a particular health blog, to check for herbal medication as alternative. I saw many comments and read many testimonies. Until i came across a particular testimony on how Dr.ugo cured a patient from herpes simplex virus using pure natural herbs. i reached out to the doctor because I also was thinking Herpes had no cure. I told him about my HIV status.He encouraged me not to panic that he will help me get my deliverance. he prepared some herbs and sent them to me. The herbs were in four 70ml bottles and I took them morning and night. i used as he directed, and in less than three weeks, i started having appetite to eat plenty of food and i gained back my strength. the fourth week,I consumed all the herbal meds. He encouraged me to go for a test which i did. This time, the result was negative. I quickly contacted the doctor and informed him of the news. I immediately asked him to prepare for Derrick too. He did and sent it. Today, me and Derrick are HIV free. All thanks goes to God Almighty for healing us through Dr.Ugo. if you are having any kind of sickness at all, Dr.Ugo is the right person to talk to and i assure you, you will be glad you did. His email: ugoherbalhome@gmail.com you can also write him on WhatsApp +2348104990619.

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  2. Nice blog
    Have been totally convinced that HIV,and many others dangerous diseases can be best cured using the Herbal Medicine. Dr.Akpu the great and powerful herbalist cured me with his Herbal remedy. I'm Linda,15 years from Texas. I was born with HIV. I lost parents at my teenager age when I was 4th. I had to grew up with my mum only Sister, whom I loved so much. She was so worried about my life as my condition was her mature problem in life. I had taken lots of antiviral treatment to get ride of the virus not believing what there said HIV has no cure. I was on the internet when i came across blogs of testimony about a lady who where cured of a 7 years diagnose of Herpes by this powerful Herbalist, Dr.Akpu.I wrote down his mail @ Dr.akpupowerherbscenter@gmail.com
    I told my Aunt,luckily it was the same Dr,we where referred to few months back by my pastor in church whom members have being testifying about of his cure We did contacted him and explained my problem to him.He prepared the medicine and sent to me with details of how to use and apply. After a while, I began to feel more strong than never before, I felt so lucky and happy when my Doctor congratulated me that he could found no HIV virus again in me. I knew I was free cos my body was so strong. His herbal medicine should have saved my parents life, i said!
    Thanks so much for reading my article, you should share your testimony if you have cure as well
    Dr.akpupowerherbscenter@gmail.com
    Is the solution

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