PEDIATRICS Case

Discussion
DR ANDREW PEREZ
Interns:
ENIOLA
DANIEL
SIDNEY IKE
 GENERAL DATA

Patient is J.A., 8 years old, male, Roman

Catholic, born on October 13, 2013, presently
residing at Urdaneta City

admitted for the first time at Region 1 Medical Center on January

14, 2021.
 CC:
Bipedal
Edema
 HISTORY OF PRESENT ILLNESS

●1 week prior to admission, patient started to experience distressing productive cough, colds with
watery nasal discharge and bipedal edema. No associated fever, vomiting or loose stools noted.
With good activity and good appetite consuming 1 cup of rice with viand per meal. No consult
done. No medications taken.
● 6 days prior to admission, still with the above signs and symptoms, now with abdominal
pain, described as dull with a pain scale of 5/10 and aggravated by movement. Patient also
noticed edema on his scrotal area. Now with decreased appetite and activity. Patient self-
medicated with Paracetamol but did not provide any relief. No consult done
 HISTORY OF PRESENT ILLNESS
Few hours prior to admission, still with the above signs and symptoms, now associated with shortness
of breath, fever with a maximum temperature of 38.9C and 2 episodes of loose stools. This prompted
the patient to seek consult. At the ER, complete blood count, urinalysis, serum albumin, creatinine,
hepa profile and lipid profile were requested. CBC revealed decreased hemoglobin and leukocytosis
with neutrophilic predominance.

Urinalysis revealed (+) blood and protein and increased RBCs, pus cells and epithelial cells. Serum
albumin was decreased (18g/L). Hepa profile revealed nonreactive HbsAg and negative HAV. Total
cholesterol was increased (240mg/dl). Patient was subsequently admitted.
 Review of Systems

 GENERAL (-) Body weakness (-) Weight loss (-) Fatigue

(-) Chills

SKIN (-) Urticaria (-) Pruritus (-) Rash

HEAD and NECK (-) Pain (-) Stiffness    

 
EYES (-) Blurry Vision  (-) Itchiness  (-) Discharges  

EARS (-) Hearing Loss (-) Discharges (-) Pain

NOSE (-) Epistaxis (-) Sneezing (-) Itch (-) Discharge

(-) Obstruction

MOUTH AND THROAT (-) Soreness   (-) Pain

(-) Odynophagia (-) Dysphagia (+) Gum bleeding

RESPIRATORY (-) Cough (-) Dyspnea (-) Tachypnea

CARDIOVASCULAR (-) Palpitation (-) Cyanosis

 REVIEW OF SYSTEMS

GASTROINTESTINAL (-) Jaundice (-) Diarrhea (-) Nausea

(-)Constipation (-) Melena

RENAL or URINARY (-) Dysuria (-) Nocturia (-) Incotinence (-) Anuria
(-) Polyuria
GENITALIA (-) Pain (-) Discharge
(-) Irritation (-) Itching
MUSCULO-SKELETAL (-) Atrophy (-) Muscle Pain (-) Weakness
(-) Cramps (-) Joint Pain (-) Limitation of motion
(-) Stiffness (-) Numbness

METABOLIC (-) Heat or Cold Intolerance

NERVOUS (-) Seizures (-) Pain (-) Syncope (-) Dizziness
(-) Tremors (-) Paralysis (-) Convulsions (+) Headache
(-) Motor, Sensory, or memory
problems

HEMATOPOIETIC (-) Pallor (-)Easy Bruisability    

 PAST ILLNESSES HISTORY

● Patient had history of chickenpox and measles with unrecalled age

● He was diagnosed with asthma and last attack was in 2005, no maintenance
medication.
● Patient is allergic to chicken and egg. No history of mumps, pulmonary
tuberculosis or seizures.
● No previous surgery, history of accidents, trauma or blood transfusion.
● Newborn screening test was normal. No history of previous dengue, was not
given vaccination for dengue.
 IMMUNIZATION HISTORY
VACCINES DOSE PLACE GIVEN
BCG 1 dose Barangay Health Center
Hep B 4 doses Barangay Health Center
Oral Polio Vaccine 3 doses Barangay Health Center
Hib 3 doses Barangay Health Center
Diphtheria, Pertussis, Tetanus toxoid,  3 doses Barangay Health Center
Measles 1 dose Private Clinic
MMR 1 dose Private Clinic

Missing Data:
● Any untoward reactions
 NUTRITIONAL HISTORY

● He was bottle fed from birth up to 3 years old and started

complementary feeding at 6 months of age, consisting of mashed
vegetable
● He eats 3-4 meals per day, mostly consisting of 2-3 cups of rice.
● His diet typically consists of pork, chicken and beef
 FAMILY MEDICAL HISTORY

●
○ Father, unknown history
○ Mother: 32 years old, vocational course graduate, housewife, apparently well.
●
 4 siblings: Sister: 12 years old, grade 6, apparently well
  Sister: 9 years old, grade 4, apparently well
       Brother: 7 years old, grade 1, apparently well
                  Sister: 2 years old, apparently well 
 Personal and Social History

He lives with his parents, in a two-storey house with 1 door, 6 windows, 4

bedrooms, and 2 comfort rooms. Primary caregiver is his grandmother.

He studies at Rosary Hills International School, and is currently in grade 9, with

good performance in school. No abuse reported

He denies taking illegal drugs. He is fond of playing chess with his neighbors and
friends. Prefers girls and had no sexual contact.
He usually sleeps 6-8 hours a day

Water supply is from Nawasa and drinking water is mineral water. Garbage is
collected 2 times per week. 
 PHYSICAL EXAMINATION

General Survey
Conscious, coherent, in mild Vital Signs
cardiorespiratory distress, with BP: 100/60 mmHG Height: 161cms
signs of some dehydration, mild  = HR: 125 bpm Weight: 60.5kgs
● RR: 28 cpm IBW: 56.3 kgs
● T° : 38.8C AC: 76 cm    
● O2 Sat: 97%
●
Skin scanty petechiae in the right antecubital area

HEENT pink palpebral conjunctiva, white sclera, slightly  sunken

eyeballs, intact tympanic membrane, pale boggy
turbinates, dry lips, moist buccal mucosa, post nasal
drip. supple neck, no palpable lymph nodes

COMMENTS:
Skin: Color of skin, skin turgor, scars, hemorrhages,
Head: Shape or contour,sutures, quantity and color of hair, hematoma,
abscess, or edema
Face: Asymmetry, unusual facies and deformities
Eyes: Discharges
Ears: Size, shape, location and position of ears. Check for ear canal for
any watery, purulent, or bloody discharge. Check the postsauricular
and mastoid areas.
Nose: Patency of nares, presence and character of discharge if
present, sinus tenderness
 PHYSICAL EXAMINATION
Chest/Lungs symmetrical chest expansion, no retractions,
clear breath sounds, good air entry

Heart adynamic precordium, tachycardic, regular

rhythm, no murmur

COMMENTS:

Chest/ Lungs Palpation:: any tenderness?

Heart Visible pulsations? PMI on the 4th intercostal space left

midclavicular line
 PHYSICAL EXAMINATION
ABDOMEN
globular, soft, tender right upper quadrant and
epigastric area, normoactive bowel sounds,
tympanitic, abdominal circumference of 76cm,
liver edge palpable 3cm below the costal
margin, with 10.5 cm liver span

COMMENS:

ABDOMEN •Inspection: size, discolorations, scars, (rashes, eruption of

erythematous, non pruritic maculopapules)
•Palpation: tenderness (rebound?, guarding?), masses,
enlargement of liver, spleen, appendix, intestine or lymph
nodes within abdomen
•Percussion: tympany, shifting dullness, liver size (express in
terms of number of centimeters of dullness)
 PHYSICAL EXAMINATION

EXTREMITIES (+) grade 2 bipedal edema

COMMENTS:

EXTREMITIES Check for deformities and mobility of

joints.
 PHYSICAL EXAMINATION
NEUROLOGIC EXAMINATION Cerebrum: Awake and alert

Cranial Nerves: 

I: can smell ethyl alcohol

II: (+) red-orange reflex, pupils equally reactive to light  
III, IV, VI: intact extraocular muscles, no nystagmus, no strabismus
V: can clench teeth, intact facial sensation
VII: no facial asymmetry, able to close eyes 
VIII: with intact gross hearing
IX & X: uvula at midline, with intact gag reflex
XI: able to shrug shoulder
XII: tongue at midline 
 PHYSICAL EXAMINATION
NEUROLOGIC Motor function Sensory function
EXAMINATION
   5/5   5/5                            100%       
100%    
  5/5       5/55                        100% 100%     

Deep Tendon Reflex: ++

Cerebellum: No nystagmus , normal gait, no tremors
Signs of meningeal irritation: No nuchal rigidity, No Kernig’s, No
Brudzinski
 SALIENT FEATURES
SUBJECTIVE OBJECTIVE
1. 8 years old, male
2. week prior to admission, patient 1. mild cardiorespiratory distress
started to experience distressing 2. Mild dehydration
productive cough, colds with watery nasal
3. slightly  sunken eyeballs
discharge and bipedal edema
3. 6 days prior to admission, still with the 4. dry lips
above signs and symptoms, now with 5. Tachycardic
abdominal pain, described as dull with a 6. Fever 38.8C
pain scale of 5/10 and aggravated by 7. tender right upper quadrant and
movement. Patient also noticed edema epigastric area
on his scrotal area 8. liver edge palpable 3cm below
4. Few hours prior to admission, still the costal margin
with the above signs and symptoms, now
associated with shortness of breath, fever
9. (+) grade 2 bipedal edema
with a maximum temperature of 38.9C
and 2 episodes of loose stools
 SALIENT FEATURES
LABS
● decreased hemoglobin and
leukocytosis with neutrophilic
predominance
● Urinalysis revealed (+) blood
and protein and increased
RBCs, pus cells and epithelial
cells
● Serum albumin was decreased
(18g/L).
● Total cholesterol was increased
(240mg/dl).
 DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT

 UPPER RESPIRATORY
POSTSTREPTOCOCCAL TRACT INFECTION
 (-) Hypertension
 (-) Hypercholesterolemia
GLOMERULONEPHRITIS  Bipedal Edema  scrotal area edema
 Fever
 Proteinuria  petechiae rash
 Hematuria
 SOB

● Poststreptococcal glomerulonephritis (PSGN) is caused by prior infection with specific nephritogenic

strains of group A beta-hemolytic streptococcus. The clinical presentation of PSGN varies from
asymptomatic, microscopic hematuria to the full-blown acute nephritic syndrome, characterized by red to
brown urine, proteinuria (which can reach the nephrotic range), edema, hypertension, and acute kidney
injury.
 DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT

• Upper Respiratory Tract

Henoch- Infection  - Arthritis
Schönlein • Edema  - Hypertension
• Hematuria
Purpura • Proteinuria
 can not totally rule out
•
Nephritis •
Elevated Cholesterol
Decreased Hemoglobin
• Fever
• Abdominal Pain
• Petechiae Rash
• Scrotal area edema

• Subcutaneous edema localized to the dorsa of hands and feet, periorbital area, lips, scrotum, or scalp is
also common.
• Ninety percent of cases occur in children, with about half the cases preceded by an upper respiratory
infection
• Some degree of renal involvement occurs in approximately 50% of HSP cases, more commonly in older
children (age > 8 yr confers a 3-fold greater risk for renal involvement)
 DIFFERENTIAL DIAGNOSIS

• RULE IN • RULE OUT

IG A • Upper Respiratory • Hypertesion

Tract Infection • loin pain
NEPHROPATHY • Edema • can not totally rule out
• Hematuria
• Proteinuria
• Elevated Cholesterol
• Decreased
Hemoglobin
• Fever
• Abdominal Pain

gross hematuria is common within 1-2 days after the onset of an apparent viral upper respiratory tract
infection in immunoglobulin (Ig) A nephropathy, and typically resolves within 5 days.
PRIMARY CLINICAL
IMPRESSION

Henoch-Schönlein Purpura Nephritis

Mild Dehydration
 INTRODUCTION
● Henoch-Schönlein purpura (HSP) is an idiopathic systemic immune complex–mediated vasculitis associated
with IgA deposition within small-vessel walls.

● most common small-vessel vasculitis in children, with a peak incidence in early childhood (4-6 yr of age).
Ninety percent of cases occur in children, with about half the cases preceded by an upper respiratory infection.

● characterized by a purpuric rash and commonly accompanied by arthritis and abdominal pain.

● 50% of patients with HSP develop renal manifestations, which vary from asymptomatic microscopic hematuria
to severe, progressive glomerulonephritis.

● HSP nephritis shares a similar pathogenesis and nearly identical renal histology with IgA nephropathy.

● Although the two are considered as distinct entities, many consider HSP nephritis and IgA nephropathy as part
of the same clinical spectrum, and IgA nephropathy as one of the sequelae of HSP nephritis.
 PATHOGENESIS AND PATHOLOGY
 deposition of polymeric immunoglobulin A (IgA) in glomeruli, analogous to the same type of IgA deposits

 Recognition of the exposed hinge region of IgA1 by naturally occurring autoantibodies leads to formation of
immune complexes that are deposited in the glomerular mesangium.

 Any mucosal infection or food antigen may trigger the increased production of pathogenic IgA1. IgA immune
complexes are deposited throughout the body and activate pathways leading to necrotizing vasculitis.

 A skin biopsy characteristically shows leukocytoclastic vasculitis with IgA, C3, and fibrin deposition.

 The glomerular findings can be indistinguishable from those of IgA nephropathy. Pathognomonic IgA deposits
are detected by immunofluorescence as the dominant immunoglobulin in the glomerular mesangium.

 Histologically, a broad spectrum of glomerular lesions that can range from mild mesangial and endocapillary
proliferation to necrotic and crescentic changes from extracapillary proliferation can be seen
 CLINICAL AND LABORATORY MANIFESTATIONS

 The classic tetrad of HSP nephritis includes a palpable purpura, arthritis or arthralgia, abdominal
pain, and evidence for renal disease.

 may develop over a period of days to weeks and may vary in their order of presentation.
Notably, not all of the tetrad are present in all patients.

 The nephritis associated with HSP usually follows the onset of the rash, often presenting weeks
or even months after the initial nonrenal manifestations have resolved.
 CLINICAL AND LABORATORY MANIFESTATIONS

 Nephritis can be manifest at the initial presentation but only rarely before onset of the rash.
Some degree of renal involvement occurs in approximately 50% of HSP cases, more
commonly in older children (age > 8 yr confers a 3-fold greater risk for renal involvement).

 Most patients (80%) initially = mild renal involvement, principally isolated microscopic
hematuria without significant proteinuria.

 About 20% of patients = severe renal involvement, including a combined acute nephritic
+ nephrotic picture (hematuria, hypertension, renal insufficiency, significant proteinuria,
and nephrotic syndrome).

 Indications for a kidney biopsy in children with HSP nephritis = significant proteinuria
(urine protein > 1 g/day or urine protein/creatinine ratio > 1.0), significant hypertension,
or elevated serum creatinine
 PROGNOSIS AND TREATMENT

 The prognosis of HSP nephritis for most patients is excellent.

Spontaneous and complete resolution of the nephritis typically occurs in the majority of patients with
mild initial manifestations (isolated hematuria with insignificant proteinuria

 children with severe clinical renal involvement (nephrotic range proteinuria,

elevated serum creatinine, hypertension):
the use of oral prednisone (1 mg/kg per day for 3 mo), along with ACE inhibitors, followed by
azathioprine or mycophenolate mofetil if severe clinical involvement persists.

 If progression to end-stage renal disease occurs:

renal transplantation is the treatment of choice
THANK YOU
 INTRODUCTION IgA Nephropathy

● IgA nephropathy is the most common chronic glomerular disease in children. It is characterized by a
predominance of IgA within mesangial glomerular deposits in the absence of systemic disease.

● A presentation with gross hematuria is common within 1-2 days after the onset of an apparent viral upper
respiratory tract infection in immunoglobulin (Ig) A nephropathy, and typically resolves within 5 days
CLINICAL AND LABORATORY
MANIFESTATIONS

● gross hematuria/microscopic hematuria and/or proteinuria

● Other presentations include acute nephritic syndrome, nephrotic syndrome, or a combined

nephriticnephrotic picture.
● Gross hematuria often occurs within 1-2 days of onset of an upper respiratory or gastrointestinal
infection
Diagnosis

● Normal serum levels of C3 in IgA nephropathy help to distinguish this disorder from
postinfectious glomerulonephritis.

● Serum IgA levels have no diagnostic value because they are elevated in only 15% of
pediatric patients.