Case of nephrotic and nephritic syndrome in children causes and treatment

1. PAEDIATRICS CASE
PRESENTATION

2. DEMOGRAPHICS
• Name: TT
• Age: 1 year old
• Sex: Female
• Address: Mungona village
• Chief: Nyanje
• D.O.A:15/09/21
• D.O.D:22/09/21

3. POPD ADMISSION
(15/09/21@11:10hrs)
• C/O :cough1/12
: fever 1/52
:abdominal distension 6/7
Hxpc:
• Hx of a cough for a month which is productive, associated
with difficulties in breathing
• Has a hx of night sweats and loss of weight
• Child also has abdominal distension which was associated
with vomiting
• Vomited twice on the day of admission, vomitus was whitish
in colour
• No hx of diarrhoea, and child was opening bowels normally

4. PMHX : this is the 2nd hospital admission
• First admission was at Levy Mwanawasa Teaching Hospital
for similar complaints and was diagnosed with TB and started
on ATT (a month)
• RVT- unknown
BIRTH HX: born at term via SVD , BWT 3.6kg,cried
immediately after birth.
IMMUIZATION HX :up to date.
NUTRITIONAL HX : still breast feeding and eats three times a
day whatever is available
FamHX: there was a Positive TB contact

5. POPD ADMISSION NOTES
ON EXAMINATION
• Wasted ( Wt for Lt < - 3 SD)
• Alert but lethargic
• Afebrile to touch
• Not pale ,not jaundice ,not cyanosis
• Oral thrush
• No signs of dehydration
• RS: Crepitations bilaterally
• CVS :S1S2 regular
• P/A : Flat , soft, non tender, with hepatomegaly
• MSS: No edema
VITALS
Temp: 370C
SPO2: 96% on air
Pulse: 113/ min
RDT –negative

6. IMP: PTB R/O Treatment Failure with Oral Candiasis in SAM
(Wasting type)
PLAN
1. FBC
2. LFTS,RFTS
3. Calpol 125mg po qid
4. Cefotaxime 300mg tds iv
5. 4 hourly vitals
6. Admit in Mbusa
7. Continue ATT

7. LAB RESULTS
FBC
• WBC 13.20* 103 MCV 79.6 fl
• HB 10.6 g/dL MCH 23 pg
• PLT 269 * 103
• NEU 6.79 * 103
• LYM 5.74 * 103
• MON 0.53* 103
Blood Smear ….NO MPS SEEN

8. BIOCHEMISTRY
• AST 90.1……………….(0.0-35.0)
• ALT 22.0………………..(0.0-45.0)
• UREA 3.98…………….(2.80-7.20)
• CREATININE 49.38……………(71.00-115.00)

9. WARD REVIEW 16/09/21 10:25
• F 1 year old
• Day 1 post admission.
• Being managed for 1) SAM 2)PTB 3) oral candidiasis
• No vomiting ,no diarrhea
• DCT was done, both mother and child tests reactive, DBS was
collected
• Started ATT ON THE 18/8/21 (3FDC1 TAB AND E 1 TAB ) with
good adherence
O/E Alert
• no pale, jaundice ,cyanosis
• not in respiratory distress

10. • Vitals: temp 38.1 C ,spo2 96% ,HR 113bpm ,WT6.1kg
• hair changes (brownish and light)
• RS: Bilateral crepitations
• CVS:S1S2 Regular
• P/A: Distended with hepatomegaly

11. PLAN
1. CXR
2. Folic acid 5mg OD
3. Mebendazole 500mg PO stat
4. Vitamin A 100,000 PO stat
5. Nystatin 100,000 IU QID PO
6. Cotrimoxazole 240mg OD PO
7. Continue with ATT
8. F-75 65mls 3 hourly
9. Start cART ABC/3TC/LPVr (mother referred to ART clinic)

12. WARD REVIEW
17/09/21@12:34 HRS
• Mother says no clinical improvement since child started taking
ATT.
• Still coughing
• No diarrhea , no vomiting
• Currently on F75
O/E wasted
• tachypnoeic
• febrile to touch
• mildly pale

13. • VITALS: SPO2 43% on air, HR 186, TEMP 38.1 C ,WT 6.09
kg
• Chest : reduced air entry on the Rt with crepitations bilaterally
CXR shows heterogeneous opacities on both R ad L
zones with increased cardiac shadow
• CVS : Gallop rhythm
• P/A : soft hepatomegaly 4cm below coastal margin
• MSS: no oedema

14. PLAN
1. ECHO
2. Continue Cefotaxime
3. Continue ART, ATT ,Pyridoxine
4. Continue Septrin, Calpol
5. Continue F 75
6. Start O2 2L/ min via nasal prongs
7. Monitor saturations
8. Move to acute bay
• 17/09/21@ 20:00
• Vitals :SPO2 83% on 2L, temp 36.7◦c.
• The plan was to increase O2 to 5L SPO2 increased to 99%

15. WARD REVIEW
18/09/21@08:55
• PTB with Oral Candiasis in SAM
• Temp spiking 38.1c
• No diarrhea no vomiting
• Having low saturations SPO2 68% on O2
O/E
• Irritable
• In respiratory distress
• Afebrile to touch
• Chest: reduced air entry on the right side with crepitations
bilaterally
• CVS: S1S2 tachycardic
• P/A : distended ,soft ,hepatomegaly

16. PLAN
1. Continue ABX
2. Continue ART,ATT
3. RUFT 2 and half sachet/day
4. F-75 130mls 4 hourly
5. Daily wts
6. Continue O2 at 5l and monitor SPO2

17. WARD REVIEW
19/09/21@07:40
• PTB with Oral Candiasis in SAM
• Child still coughing
• Temperature has come down
VITALS:SPO2 95% on 5L O2, HR 113bpm,TEMP 36.9C
PLAN
1)Stop nystatin
2)Fluconazole 50mg OD IV
3)Continue ATT,ART,ABX
4) Continue O2
5) Continue F 75

18. WARD REVIEW 20/09/21 10:00
• 1 yr old being treated for PTB with Oral Candiasis in SAM
• Temp has come down
• No vomiting ,no diarrhea
• On Cefotaxime , Fluconazole, Septrin
O/E
• Asleep
• In respiratory distress
• Subcoastal and intercoastal recession
• Tachypnoeic
• SPO2 99%, TEMP 37.2C,WT 5.89kg
• Chest: bilateral crepitations
• CVS: S1S2 Regular
• P/A soft

19. PLAN
1. Stop F 75
2. Start f 100 130 mls 4 hourly
3. Continue ABX, and Septrin
4. Continue ATT ,ART
5. Keep on O2

20. WARD REVIEW 21/09/21 13:10
• Child is lossing weights
• Admission wt 5.9kg
• Current wt 5.7kg
• On Calpol, Cefotaxime,F/A, and Fluconazole
O/E
• In respiratory distress with marked subcoastal and intercoastal
recessions
• On O2 5l/min SPO2 87%
• Chest: bilateral crepitations
• CVS:S1S2 regular ,tachycardiac with gallop rhythm and
murmur in 2nd intercoastal space

21. PLAN
1. Close Cefotaxime
2. Continue ATT, ART, Fluconazole
3. Furosemide 10mg OD IV
4. Continue O2
5. ECHO when child is stable

22. 22/09/21@ 03:30hrs
• Called to review pt
• Child had started gasping
O/E
• Pupils were fixed and dilated
• No cardio – pulmonary activity
• Certified dead
• CAUSE OF DEATH:PULMONARY TUBERCULOSIS
WITH SAM IN RVD