Case 1: 8-year-old with Brown Urine
An 8-year-old girl was brought to the Emergency Department by her mother, complaining of brown-colored urine for 4 days. She had a sore throat 2 weeks ago which resolved spontaneously.
The mother noticed mild swelling (puffiness) under her eyes in the last 2 days.
She also complained of headache and scanty urine for the last 1 day. On physical examination: HR:110, RR:26, BP: 140/90, Temp: 37.6. The child appeared pale. Cardiovascular System (CVS) Exam: Gallop rhythm, no cardiac murmur. Urine Dipstick Analysis: Significant proteinuria and hematuria.
a- Relevant questions to ask the mother:
- Has she had any recent fever or symptoms of infection other than the sore throat?
- Has she experienced any swelling anywhere else, such as in her legs or face?
b- Important specific signs to look for during examination:
- Edema: Specifically, look for periorbital edema and assess for pitting edema in the lower extremities.
- Hypertension: Accurately measure and monitor blood pressure.
c- Important investigations:
- Urine Microscopy: To assess the type of cells and casts present, further characterising the hematuria.
- Renal Function Test (Serum Electrolytes, Creatinine and Urea): To assess the extent of kidney injury and complications.
d- Most likely diagnosis and differential diagnoses:
- Most Likely Diagnosis: Post-Streptococcal Glomerulonephritis (PSGN).
- Differential Diagnoses:
- IgA Nephropathy (Berger’s disease).
- Hemolytic Uremic Syndrome (HUS).
e- Important points in the management plan:
- Fluid and Electrolyte Management: Careful monitoring and control of fluid intake and output due to potential volume overload and electrolyte imbalances.
- Blood Pressure Control: Management of hypertension with appropriate anti-hypertensive medications.
Case 2: 11-year-old with Abdominal Pain, Joint Pain, and Rash (HSP)
Scenario
An 11-year-old female presents with complaints of recent development of abdominal pain, joint pain, and a new skin rash. Her stool is positive for Occult Blood Test.
1 - Relevant questions to ask the mother:
- 1-Ask about a recent history of Upper Respiratory Tract Infection (URTI)?
- 2-Ask about any rash noticed on the buttocks and lower limbs?
- 3-Ask about Gastrointestinal (GIT) signs like abdominal pain, nausea, vomiting, paralytic ileus, GI bleeding, bowel perfusion, and intussusceptions.
- 4-Ask about Arthritis/Arthralgia, usually oligoarticular, and in the lower extremities?
- 5-Ask about hematuria (blood in urine)?
2- Examination findings:
- 1- Vital signs (Blood Pressure (BP), Pulse Rate (PR), Respiratory Rate (RR), & Temperature (TEMP))
- 2- General examination.
- 3- Because Henoch-Schönlein Purpura (HSP) can affect all organ systems, a full physical examination is indicated.
3- Investigations to order:
- 1- Usually a clinical diagnosis.
- 2- Complete Blood Count (CBC), C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Urea and electrolytes. Renal function test, urinalysis, coagulation profile, stool analysis.
- 3- Abdominal Ultrasound (US), abdominal X-ray (to rule out GI pathology).
4- Differential Diagnoses (DDX):
- 1- Acute Glomerulonephritis
- 2- Acute Renal Failure
- 3- Bacterial Endocarditis
- 4- Child Abuse & Neglect: Physical Abuse
- 5- Disseminated Intravascular Coagulation
- 6- Idiopathic Thrombocytopenic Purpura.
5- Management:
- 1- Usually supportive (hydration, rest, and pain medication).
- 2- If severe abdominal pain, rule out GI pathology; give prednisolone if no GI problem.
- 3- For arthritis: short term use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).
A 5-year-old Saudi male presented to the emergency room with his parents, complaining of generalized fatigue and significant swelling in his legs and puffiness under his eyes for two days prior to admission. These symptoms were associated with foamy urine. He had a sore throat one week before the onset of swelling, which resolved spontaneously. He also has a history of allergies to dust and bakhoor.
On physical examination, his heart rate was 90 beats per minute, respiratory rate was 18 breaths per minute, blood pressure was 90/60 mmHg, and temperature was 37.6°C. There was bilateral periorbital edema and pitting edema in the lower extremities. Cardiovascular examination revealed normal heart sounds with no cardiac murmur. Urine dipstick analysis showed proteinuria 4+.
Relevant Questions:
- Has the child experienced any recent infections or illnesses other than the sore throat?
- Are there any family members with a history of kidney disease or similar symptoms?
Related Investigations:
- Serum albumin and cholesterol levels.
- Renal ultrasound.
Likely Diagnosis and Differentials:
- Likely Diagnosis: Nephrotic Syndrome
- Differential Diagnoses: Minimal Change Disease, Post-streptococcal Glomerulonephritis
Management:
- Initiate corticosteroid therapy for nephrotic syndrome.
- Monitor and manage fluid balance and edema.
Asymptomatic Causes of IgA Nephropathy:
- Genetic predisposition
- Mild or subclinical infections
Urine Casts and Analysis:
- Presence of proteinuria, glucosuria, and polymorphonuclear leukocytes can indicate kidney involvement.
Questions for Post-streptococcal Glomerulonephritis:
- Was there any recent history of skin infections or pharyngitis?
- Are there any signs of hematuria or hypertension?
Case
A 2-year-old boy presents with extremity swelling and protein found on urine analysis. Minimal-change disease is suspected and you explain to the child’s parents that this diagnosis: Is the most common cause of nephroticsyndrome in childhood
: Urine Discoloration
Questions
- A-What is this sign called?
- B-give two Ddx to it?
- C-mention one important thing in history to ask about it?
- D-the uncle has the same symptom what is the confirmatory test?