Sdns with toxicity

Welcome to clinical meeting

Dr. KANTA HALDER Resident (MD;Phase A)

BICH

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.

Chief Complaints

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

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.

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.

Cont.. His first relapse occurred while on alternate

day prednisolon and subsequent attack occurred 7 days after completion of treatment with oral prednisolone.

History of Past illness He had no significant past illness.

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.

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.

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.

Developmental History He is developmentally age appropriate.

General Examination Appearance: Puffy face with cushingoid

appearance, hypertrichosis present.Anaemia:Jaundice: Cyanosis:Clubbing: AbsentDehydration:Oedema: ++

Cont..Skin: BCG mark present.Lymphnode: Not palpable.Ear:Nose: NormalThroat:Bedside Urine Albumin: +++

Cont..Vital Signs:

Pulse: 100/min.Respiratory Rate: 26/min.Temperature: 98°F.Blood Pressure: 90/60 mmHg.

Anthropometry:

Cont..

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

Systemic ExaminationAbdominal Examination: Inspection:

Abdomen is mildly distended.Flanks are full.

Umbilicus is centrally placed with transversely slit.

Cont.. Palpation :

Abdomen is non tender. Liver: Not palpable. Spleen: Not palpable.

Kidneys: Not ballotable. Renal angle: Not tender. Fluid thrill: Absent.

Cont.. Percussion: Shifting dullness: present. Auscultation:

Bowel sound: present. Genitalia: Normal. Other Systemic examination: No abnormality.

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.

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.

Provisional Diagnosis

Steroid Dependant Nephrotic syndrome with Steroid toxicity.

Investigations Urine R/M/E:

Color: Straw.Appearance: Clear.Albumin: +.RBC: Nil.Pus cell: 4-6/HPF.

Urine C/S: Klebsiella pneumoniae.

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.

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%

Cont..

o RBC: Normocytic normochromic.o WBC: Mature with above

distribution.o Platelet: Adequate.

• Platelet: 415,000/mm3.• PBF:

Blood C/S: No growth.

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.

Final Diagnosis

Steroid Dependant Nephrotic syndrome with Steroid toxicity with Urinary Tract Infection.

ManagementCounseling 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.

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.

Follow Up

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

days.

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%

Cont..

o RBC: Normocytic normochromic.o WBC: Mature with above

distribution.o Platelet: Adequate.

• Platelet: 446,000/mm3.• PBF:

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.

Follow Up

• Renal biopsy was done on 03.04.2016.• Patient was discharged with advice for follow

up after 2 weeks with biopsy report.

Thank You