Clinical Meeting on Infrequent Relapse Nephrotic Syndrome

1. Welcome
To
Clinical Meeting
Presented by
Dr Aklima
Medical Officer
Medical College For Women and Hospital

2. Particulars Of The Patient:
Name: Jannat
Age: 5 Years
Sex: F
Address: Tongi, Gazipur
Date of Admission: 12.06.2023
Date of Discharge: 19.06.2023

3. Chief Complaints:
1. Generalized swelling for 4 days
2. Scanty micturition for 3 days
3. White precipitation of urine during boiling for 3 days

4. HISTORY OF PRESENT ILLNESS
• According to the patient’s mother’s statement the patient was
reasonably well 4 days back. Then she developed swelling of whole
body which first appear on periorbital region then gradually became
generalized. She also developed scanty micturition and white
precipitation of urine during boiling for 3 days. She had no history of
burning micturition, haematuria, unconsciosness, convulsion or
abdominal pain.

5. HISTORY OF PAST ILLNESS:
She had history of same type of illness previously, 1st attack at 4 years
of age and 2nd attack 10 months back. Each attack she was treated with
tab prednisolone with adequate dose and duration
BIRTH HISTORY:
She was delivered by NVD at term without any antenatal, natal and
postnatal complication.

6. FEEDING HISTORY:
She was exclusively breast fed up to 6 months. Then complementery
feeding was started & now on family diet.
IMMUNIZATION HISTORY:
Immunized as per EPI schedule.

7. DEVELOPMENTAL HISTORY:
Age appropriate.
TREATMENT HISTORY:
Nothing contributory.
FAMILY HISTORY:
1st issue of non-consanguineous parents. No history of such kind of
illness in family.
SOCIOECONOMIC HISTORY:
She came from a higher middle class family.

8. GENERAL EXAMINATION:
Appearance: Conscious, cooperative, puffy face
Pallor: Absent
Jaundice : Absent
Cyanosis : Absent
Oedema : Present (+++)
Dehydration :Absent
Clubbing : Absent
Koilonychia: Absent
Leukonychia: Absent
Lymph Node: Not Enlarged

9. R/R: 26 br/min
Pulse: 88 b/min
BP:90/60 mmHg which lies on 25th centile
Temp.: Normal
Anthropometry:
Weight: 16.9kg
BSA: 0.69m²
BSUA: ++++
Skin survey: Normal
BCG mark: Present
Ear, Nose, Throat: Normal

10. SYSTEMIC EXAMINATION
Alimentary SYSTEM:
Mouth and oral cavity: Healthy
Inspection:
Abdomen distended, flank full.
Umbilicus centrally placed and everted with transverse slit.

11. Palpation:
• No palpable mass
• Liver: Not palpable
• Spleen: Not palpable
• Kidney: Not ballotable
• Fluid thrill: Present
• Genitalia : Normal

12. • Percussion :
Shifting dullness : Absent
• Auscultation :
Bowel sound : Present
• Other systemic examination reveals nothing abnormality.

13. SALIENT FEATURES
Jannat 5 years old girl 1st issue of non-consanguineous parents,
immunized as per EPI schedule hailing from Tongi admitted here with
the complaints of swelling of whole body which 1st appear on
periorbital region then gradually became generalized for 4 days, scanty
micturition and white precipitation of urine during boiling for 3 days.
She had no history of dysuria, haematuria, abdominal pain. She had
history of previous attack, 1st attack at 4 years of age and 2nd attack 10
months back.

14. Each attack was treated with tab prednisolone with adequate dose and
duration. On examination she is conscious, co-operative, having puffy
face, oedematous,BP- 90/60 mmof Hg which lies on 25th centile,
pulse-88b/min, wt-16.9 kg which lies on 25th centile, BSA- 0.69 m²,
BSUA- +++.Abdomen is distended, flank full, umbilicus centrally placed,
everted, transversely slitted, ascitis present evidence by fluid thrill.
Other systemic examination reveals nothing abnormality.

15. PROVISIONAL DIAGNOSIS
?

16. PROVISIONAL DIAGNOSIS
Infrequent Relapse Nephrotic Syndrome

17. INVESTIGATION:
CBC:(10/06/23)
Hb: 13gm/dl
ESR: 70 mm in 1st hr
TC of WBC: 9000/cumm
DC of WBC:
N-44%, L-43%, M-03%, E-10%
Platelet:2,42,000/cumm

18. Urine (R/E): (11/06/23)
Colour : Straw
Appearance : Slightly Hazy
Protein (Albumin): +++
RBC: Nil
Pus cell: 15-17/HPF
Epithelial cell: 4-5/HPF

19. • Spot Urinary Protein Creatinine ratio : 25.92 (11/06/23)
• Serum Albumin: 2 g/dl (10/06/23)
1.8 g/dl (17/06/23)
• Serum Cholesterol :309 mg/dl (11/06/23)
• Serum Creatinine : 0.28 mg/dl (10/06/23)
0.38 mg/dl (17/06/23)
• Urine for C/S : No growth (13/06/23)

20. FINAL DIAGNOSIS
Infrequent Relapse Nephrotic Syndrome
With UTI

21. MANAGEMENT
Counseling the parents about the nature, treatment & prognosis of the disease.
Supportive Treatment:
1. Diet: Neutropenic
2. Fluid & salt restriction
3. Fluid: PDO + 400 ml/m²
3. Inj. Ceftriaxone
4. Inj. Amikacin
5. Tab. Frulac (20/50)
6. Inj. Albumin
6. Calcium tab.
7. Syp Famotidine

22. Specific Treatment:
• Prednisolone: 60 mg/m² single morning dose every day upto
remission.
Then-
40 mg/m² single morning dose every alternate day for 4 weeks &
gradually taper over 4 to 8 weeks

23. FOLLOW UP
In hospital-
• Daily intake and output
• Oedema
• Weight
• BP
• Abdominal girth
• Bed side urine albumin
• BSA
• Any infection
• Any complication

24. After discharge –
• Bed side urine albumin : Once or twice in a week
• Steroid toxicity : 3 monthly BP, anthropometry
Yearly – Cataract
• Renal functional status: S. creatinine