Nephrotic Syndrome, persistant vomiting, anuria and hypotension

Ridwan, aged 8 years, is a case of Nehrotic Syndrome. He is suffering from NS since the age of 3 years. He has repeated attacks over the years. This is his 8th relapse. He is a case of Minmum Change Nephrotic Syndrome.



Each time he responded to oral prednisolone. But this time he develops persistant vomiting . Vomiting is so severe that he develops anuaria which is partly contributed by low albumin in his blood.

We admitted the patient in the hospital and investigate. His serum electrolytes reflected hyponatrimia, hypochloramia and hypokalamia.

We exclude any infection and peritonitis. We conclude that the vomiting is prednisolone induced.

We stop the drug and switch over to I/V Methyl Prednisolone. He has kept on Methyl Prednisolone for 10 days.

We also have to give him I/V albumin for 3 days as the diuretics are not enough to induce urination.

When vomting stops and the patied sattled and urine become albumin free, we switch over to oral prednisolone and discharge the patient from the hospital.



Bdoza

Acute Hepatitis induced by prolonged use of Sodium Valproate

She has developed jaundice for the last 7 days. She is 4 and 7 months of age. No other complaints. No fever, no nausea or vomiting. even no abdominal pain, only anorexia.
But she was taking Sodium Valproate (Sup Valex) for the last 4 years. She was given this drug after convulsions at the age of 6 months. Since then she had no further convulsion and continued to take the medicine till date. She was vaccinated in infancy against Hepatitis B.

On examination, the patient was found moderately icteric.Liver was enlarged 8 cm, mildly tender. Other systems were normal.

Serum bilirubin was found 5.3 mg/dl, SGPT 535 IU/dl, Alkaline phosphatase 1388 IU/dl. Her HBsAg was found negative, prothrombin time normal.
Ultrasonography was consistent with Acute inflammation of the liver.

We conclude this could be a case of Acute Hepatitis induced by prolonged use of Sodium Valproate.
We withdrew the drug.,admit the patient in the hospital for better observation.
Patient was gradually improving. After 7 days, we repeat the Liver Function test. The Serum bilirubin come down to 1.3 mg/dl, SGOT 57 IU/dl, Alkaline Phosphatase 103 IU/dl.

Patient was discharged with advice to come after 7 days for follow up.


Bdoza

Down Syndrome with truncus solitarius, cardiomegaly and severe anaemia

The girl admitted for severe pallor. She was a 7 year old girl with poor socioeconomic background. She had clinical features suggestive of Down Syndrome with facial dysmorphism, hypotonia, developmental delay and low IQ.

On examination, she was found to be severely anaemic. No clue could be identified for such a degree of anaemia. Possibility of malaria, leukemia, thalassemia were excluded clinically and by blood examinations.

There was cardiomegaly but no murmer. On Xray , lung field was translucent and there was no sign of pulmonary oedema.

Echocardiographist identified ‘truncus solitarius’ and pericardial effusion.

For pericardial effusion, we are searching for cause, tuberculosis is a possibility.

Bdoza

Sturge Weber Syndrome with repeated convulsion and mental retardation

A boy of 5 years has a 'birth mark' over the forehead since birth. He had developmental delay of milestones and mental retardation. He had his first convulsion at the age of 6 months- generalised tonic clonic in nature and which had recurred off and on. He was prescribed at anticonvulsants at different times but couldn't take the medicine regularly because of poverty.

His x-ray skull was normal and CT Scan could not be done due to lack of money.

But the pink port wine stain, developmenatl delay, mental retardation and repeated convulasion all these conform clinically to Sturge Weber Syndrome.

Bdoza

GBS, ascending paralysis and respiratory failure

A boy of 3 years presented with limping and weakness of the lower limbs of acute onset.

After admission, his paralysis was deepened in the lower limbs and the upper limbs developed paresis.

When the patient shifted to our ward, he was already in respiratory distress.

His was conscious but his Bayniski’s sign was negative and reflexes in the limbs were absent. His pulse was rapid and blood pressure norrmal.

His bladder and bowel were not affected.

The case was diagnosed as GBS (Gullain-Barre Syndrome) with ascending paralysis with respiratory failure

We have taken all supportive measure and at one stage the patient was intubated but the patient deteriorates rapidly and expires.

Bdoza

Enteric fever with hypothermia, shock and myocarditis

A child of 6 years presented with 14 days fever and rt upper abdominal tenderness. He was lebelled as 'Enteric Fever' and admitted in hospital for parenteral medication(30/5/07). Among lab test, widal test was found positive. On the second day of hospital, he developed hypothermia and shock. Pt was transfered to critical care unit and managed. Pt recovered from hypothermia and shock after 48 hours of intensive manuevre with blood, fluid, dopamine, dulbutamine, nasogastric suction and oxygen. Ceftrixone was contuied but oral Azithromycin has to replaced with IV ciprofloxacin.

When the patient become stable and we were feeling a little relaxed, the patient developed respiratory distress and little puffiness of the face. We vealuate the renal funtions- his output was normal, serum creatinine and electrolytes was found normal.

On auscultation, pt had bilateral crepitaions and tender hepatomegaly. Pulse was 142/m, BP 105/70, Ultrasonograpgy of the abdomen was found normal. Xray shows mild pulmonary edema. Myocarditis with heart was suspected and pt improved after giving Inj Lasix and lasix prescribed for twice a day.

Pt's fever was persisting and oral Azithromyecin was added. But the patient develops hypothermia again in late hours of the day(5/5/07). To raise the temparature, blanket was used and pt was given steroid in Inj form. His pulse, BP,bowel was normal. So, is the hypothermia is a beacuse of toximia?Pt was also irritable and restless then.

By morning the patient become a bit settled, distress decreased and temparature normalised.

We are still fighting for the patient.(6/6/07). Not yet sure about the outcome.

Bdoza

Choroid Plexus Papilloma with hydrocephalus and loss of speech

A boy of 9 years was suffering from seizure disorder for the last 5 years. He had occassional vomiting and headache for the last eight months. He lost his speech since one week.
On examination he was found to have hemipresis on the right side and facial palsy on the left side.
He was on Sodium valproate for convulsion.

CT scan shows Choroid Plexus Papilloma with hydrocephalus. Other tests -Blood CBC, Renal function and liver function are normal.

The patient was refered to the Neurosurgery Department for surgical management.




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