Clinical meeting Paediatrics

1. Dr. KANTA HALDER
Resident (MD;Phase A)
BICH

2. Particulars of the patient
 Name: Tamim.
 Age: 3 years.
 Sex: Male.
 Address: Demra, Dhaka.
 Date of Admission: 15.03.2016.
 Date of Examination: 19.03.2016.

3. Chief Complaints
 Swelling of whole body for 15 days.
 Scanty micturition for same duration.
 Fever for 3 days.
 Abdominal pain for 3 days.

4. History of present illness
According to the statement of mother, her
child developed swelling of whole body for 15
days which first appeared at face and then
gradually became generalized. He also
developed scanty micturition for same duration
which was normal in colour, but there was
white precipitation on boiling. He also
complained of low grade intermittent fever and
abdominal pain for 3 days.

5. Cont..
For these complaints, they came to DSH
nephrology follow up & did some
investigations and then admitted for further
evaluation & better management. He had no
H/O cough, burning sensation during
micturition, diarrhoea, headache or
convulsion. He had same type of attacks 4
times in last 1½ year & his initial episode was
at his 1½ years of age. Each time he was
admitted in DSH & treated adequately.

6. Cont..
His first relapse occurred while on alternate
day prednisolon and subsequent attack
occurred 7 days after completion of treatment
with oral prednisolone.

7. History of Past illness
He had no significant past illness.

8. Treatment History
He was treated adequately with oral
prednisolone during his 1st & 2nd hospital
admission, but developed proteinuria during
alternate day prednisolone therapy & 7 days
after completion of steroid respectively. During
3rd admission he was treated with tab. Levamisol
along with alternate day oral prednisolone, but 1
month after starting treatment, his last relapse
occured. During last attack he was treated with
oral cyclophosphamide for 3 months.

9. Birth History
He was delivered normally at term without
any complication.
Feeding History
He is on family diet.
Immunization History
He is immunized as per EPI schedule.

10. Familly History
He is the only issue of his non-
consanguineous parents. Her other family
members are healthy.
Socio-economic History
He belongs to a middle income family.

11. Developmental History
He is developmentally age appropriate.

12. General Examination
Appearance: Puffy face with cushingoid
appearance, hypertrichosis present.
Anaemia:
Jaundice:
Cyanosis:
Clubbing: Absent
Dehydration:
Oedema: ++

13. Cont..
Skin: BCG mark present.
Lymphnode: Not palpable.
Ear:
Nose: Normal
Throat:
Bedside Urine Albumin: +++

14. Cont..
Vital Signs:
Pulse: 100/min.
Respiratory Rate: 26/min.
Temperature: 98°F.
Blood Pressure: 90/60 mmHg.

15. Anthropometry:
Cont..
Weight: 17 kg.
Height: 87 cm.
HAZ: - 2.3 SD (moderately stunted).
WHZ: + 14.6 SD (normal).
BSA: 0.7 m2.

16. Systemic Examination
Abdominal Examination:
Inspection:
Abdomen is mildly distended.
Flanks are full.
Umbilicus is centrally placed with
transversely slit.

17. Cont..
Palpation :
Abdomen is non tender.
Liver: Not palpable.
Spleen: Not palpable.
Kidneys: Not ballotable.
Renal angle: Not tender.
Fluid thrill: Absent.

18. Cont..
Percussion:
Shifting dullness: present.
Auscultation:
Bowel sound: present.
Genitalia:
Normal.
Other Systemic examination: No abnormality.

19. Salient feature
Tamim, 3 years old immunized boy presented
with anasarca, oliguria and proteinuria for 15
days. He also had low grade, intermittent
fever & abdominal pain for 3 days.He had H/O
same type of attack for 4 times in last 1½
years and treated with oral Prednisolone &
other alternative drugs with adequate dose
and duration.

20. Salient feature (cont..)
His first relapse occurred while on alternate
day prednisolon and subsequent attack
occurred 7 days after completion of treatment
with oral prednisolone. He is oedematous,
having puffy face with cushingoid appearance.
There is hypertrichosis, bed side urine
albumin was +++. There is ascites without
organomegaly. His vitals are within normal
limit.

21. Provisional Diagnosis
Steroid Dependant Nephrotic syndrome with
Steroid toxicity.

22. Investigations
 Urine R/M/E:
Color: Straw.
Appearance: Clear.
Albumin: +.
RBC: Nil.
Pus cell: 4-6/HPF.
Urine C/S: Klebsiella pneumoniae.

23. Cont..
 B. Urea: 14.0 mmol/L.
 S. Creatinine: 32.0 µmol/L.
 S. Electrolytes:
Na+: 133.0 mmol/L.
K+: 5.3 mmol/L.
Cl-: 100.0 mmol/L.
 S. Albumin: 10.0 mmol/L.
 S. Calcium: 1.86 mmol/L.
 CRP: 6.0 mg/L.

24. Cont..
Complete Blood Count :
• Hb: 13.3 gm/dl.
• WBC: Total count: 19,300/mm3.
Differential count:
o Neutrophil: 64%
o Lymphocyte: 30%
o Monocyte: 03%
o Eosinophil: 03%
o Basophil: 00%

25. Cont..
o RBC: Normocytic normochromic.
o WBC: Mature with above
distribution.
o Platelet: Adequate.
• Platelet: 415,000/mm3.
• PBF:
Blood C/S: No growth.

26. Cont..
 USG of KUB:
Bipolar length of Right kidney is 8.2 cm.
Left kidney is 8.6 cm.
Both are enlarged in size according to size.
There is raised both renal parenchymal
echotexture due to medical renal disease.
Cortex & medulla of both kidneys are ill
defined.
Comment: Bilateral raised both renal
parenchymal disease.

27. Final Diagnosis
Steroid Dependant Nephrotic syndrome with
Steroid toxicity with Urinary Tract Infection.

28. Management
Counseling to the parents.
 General treatment:
• Normal balance diet with adequate protein
(2-2.5 gm/kg/day).
• Calcium & Vit-D supplementation: 1000 mg of
elemental calsium.
• H2 blocker: Syp. Ranitidine 1 tsf 12 hourly.

29. Cont..
 Treatment of UTI:
Inj. Ceftriaxone 1 gm once daily.
 Specific treatment :
Tab. Prednisolone 15mg (1 mg/kg/day) in
single morning dose.
Tab. Tacrolimus 1.5 mg (0.1 mg/kg/day)
once daily.

30. Follow Up
• Renal biopsy was planned.
• Urine C/S: Streptococcus sp.
• Inj. Vancomycin was added continued for 10
days.

31. Investigations (cont..)
Complete Blood Count :
• Hb: 11.7 gm/dl.
• WBC: Total count: 13,100/mm3.
Differential count:
o Neutrophil: 68%
o Lymphocyte: 30%
o Monocyte: 01%
o Eosinophil: 01%
o Basophil: 00%

32. Cont..
o RBC: Normocytic normochromic.
o WBC: Mature with above
distribution.
o Platelet: Adequate.
• Platelet: 446,000/mm3.
• PBF:

33. Cont..
 Urine C/S: No growth.
 Bleeding time: 3 min 30 sec.
 Clotting time: 6 min.
 Prothrombin time: 10 sec.
 Anti-HBsAb: Positive.
 Anti HCV: Negative.

34. Follow Up
• Renal biopsy was done on 03.04.2016.
• Patient was discharged with advice for follow
up after 2 weeks with biopsy report.

35. Thank You