Luis, Joan

Luy, Therese Marie

CASE PRESENTATION
Magat, Maria
Maglana, Christopher

Pediatric Rotation
General Information

Name: Patient PE
Sex: Female
Age: 6 years old
Birthdate: December 19, 2009
Address: Sta. Cruz, Davao del Sur
Nationality: Filipino
Religion: Roman Catholic
Admission Details

Hospital: Southern Philippines Medical Center

Pediatric Nephrology Unit
Date/Time: November 5, 2015 11:30 pm

Informant: Grandmother
Reliability: 80%

Date & Time of Interview: November 10, 2015 4:00 pm

Chief Complaint

Rash, Abdominal Pain and

Vomiting
Present Health History

9 days prior to admission

Undocumented fever intermittent and high grade

Given Paracetamol syrup, 1 teaspoon (5 ml), 4 times
per day with temporary relief
Present Health History

4 days prior to admission

Nonpruritic rashes distributed evenly over the lower extremity
and buttocks, described as pink to reddish, slightly raised,
irregularly shaped, well-demacated lesions, measuring an
average of 1 to 3 cm (palpable purpura)
Bilateral pitting edema, grade 1 on patients both hands and
feet
Sudden, intermittent joint pains particularly on the ankles,
knees, and wrists, with an intensity of 10/10, associated with
difficulty standing and walking. Pain is relieved by resting.
Present Health History

4 days prior to admission

Diffuse, crampy, intermittent abdominal pain, with intensity of

8/10, not associated with diarrhea, constipation, or bloody
stool.
Loss of appetite
Brought to a manghihilot but found no relief
Given Amoxicillin syrup, 1 teaspoon (5ml), given 4 times a day
and Paracetamol of the same dose for fever with no relief
Present Health History

Hours prior to admission

Persistence of symptoms, now associated with post-prandial

vomiting, non-blood streaked, non-bilous, consisting mostly of
food particles, non-foul, amounting to an average of 100 ml per
output
At SPMC-ER, patient had urinalysis and was found to have
microscopic hematuria and thus was advised for admission
Past Medical History

Birth/Pregnancy History
Patient is the first born
G1P1 (1001) mother
full term via NSVD
no prenatal care
no health problems or complications during and after
pregnancy
Past Medical History

Medical & Surgical History

No previous hospital admissions
No prior medical or clinic consultations done
Occasional fever, cough, and flu last episode one month ago
Past Medical History

Allergies
No known allergies to any foods, drugs or medications

Medications
Had taken occasional over-the-counter drugs for fever like
paracetamol
Currently taking multivitamins syrup, 1 teaspoon per day
Past Medical History

Diet
Exclusively breastfed until 9 months; thereafter, she was given
complementary food in the form of Nestogen, Cerelac and
lugaw

Usual recent diet is composed of rice, meat, and vegetables

with no problems during feeding. Occasionally junk foods and
candies are also consumed.
Past Medical History

Growth and Development

1 year old- first tooth eruption

1 year old and 3 months- can stand
1 year old and 8 months- can walk
2 years old- combines two-three words in phrases/sentences
Past Medical History

Growth and Development

6 years old
able to write her name legibly, read simple words, basic
counting and calculation
Able to ride a bike
Can dress, take a bath, and eat independently
Past Medical History

Immunization

Fully immunized child

Completed her immunization at a health center
Past Medical History

Maternal Side
(-) cancer, diabetes, hypertension, cardiac diseases, obesity
(+) pulmonary tuberculosis grandfather (no exposure)

Paternal Side
Not known
Past Medical History

Personal and Social

Attends a public school as a grade one student

Friendly, active and playful girl who loves to learn
Very fond of riding the bike
No siblings
Lives with her mother, grandmother and 10 year old uncle
Past Medical History

Environmental History

Lives in a small but concrete house, well-lit, well-ventilated and

always kept clean
No pets
No smokers in the house
No recent travel nor exposure to ill people.
 Review of Systems

General: No weakness, easy fatigability, or significant weight loss.

Skin: No itching, sores, bruising or pigmentations; no changes in hair
and nails.
Head: No history of head injury.
Eyes: No significant visual dysfunction.
Ears: No deafness, tinnitus, or discharges.
Nose and sinuses: Episodes of occasional epistaxis. No obstructions
or abnormal discharges.
Review of Systems

Mouth and Throat: No bleeding gums or sores. No history of sore

throat and tonsillitis.
Neck: No stiffness or limited range of motions.
Respiratory: With history of occasional cough and flu. No history
of dyspnea, hemoptysis, wheezing, or asthma
Cardiovascular: No chest pain, palpitations, or syncope
Review of Systems

Gastrointestinal: No nausea, dysphagia or food intolerance. No

reported changes in bowel habits or significant stool changes. No
hemorrhoids.
Genitourinary: No dysuria, flank pain, or urinary incontinence and
frequency
Musculoskeletal: No significant muscle wasting.
Endocrine system: No significant polyuria or polydipsia. No heat and
cold intolerance or any abnormal sweating.
Physical Examination

Vital signs Measurement Interpretation

Heart Rate 111 bpm Normal

Respiratory Rate 22 cpm Normal

Temperature 36.5C Afebrile

Blood Pressure 100/60 mmHg Normal

Physical Examination

Anthropometric Measurements

Height 115cm

Weight 16.7kg

BMI 12.6 (Underweight)

Z-score: -1
Normal
Z-score: -2
Underweight
Z-score: -2
Wasted
General

Awake, alert, coherent and cooperative

Thin habitus, sitting on the bed.
Shows minimal discomfort and occasional
abdominal guarding
Not in respiratory distress
Skin

Petechial rash admixed with minimal palpable purpura

distributed evenly over the lower extremities
Warm and moist with good skin turgor
Nail beds are pink with capillary refill time of less than 2
seconds
No jaundice, pallor, cyanosis, scars or ulcerations, palpable
masses or nodules
HEENT

Ears

Pinnae without deformities, lumps, or skin lesions

Pinnae are in line with the outer canthus of the eye
No discharges and lesions
HEENT

Nose
Nasal mucosa is pink
Nasal septum in midline
No sinus tenderness
Nostrils patent, without nasal flaring
No nasal polyps, ulcers, or bleeding
HEENT

Throat
Lips are dry, pink, without lumps, ulcers, cracking, or
scaling
Oral mucosa pink, moist, without ulcers, white
patches, or nodules
Tongue is pink, in the midline
Uvula is in the midline, without any deviation
No tonsillar hypertrophy or pharyngeal exudates
Neck

Trachea is in midline, without deviation

Thyroid gland moves up with swallowing
No palpable lymph nodes or enlargement of
thyroid
No nuchal rigidity.
Respiratory

Chest is symmetrical, without deformities or

retractions
Breathing is spontaneous, no retractions or use of
accessory muscles noted
No tenderness or masses noted
Tactile fremitus equal on all lung fields
Resonance noted, equal on all lung fields
Clear breath sounds heard in both lung fields
Cardiovascular

Adynamic precordium
No heaves, thrills noted
PMI at 5th intercostal space,midclavicular line
Heart rate and rhythm is normal
S1 softer than S2
Extra sounds and murmurs not heard
 Gastrointestinal

Non-protuberant abdomen with a circumference of 54cm

No scars, dilated veins and striae noted
No distention, rigidity noted
Normoactive bowel sounds heard, 6 per minute, with
occasional borborygmus
Tympanitic abdomen
Tenderness on RLQ upon light palpation
No masses, liver edge not palpable
Negative for Rovsings and Psoas maneuver
Genitourinary

No discharges or lesions noted

No costovertebral angle tenderness
Negative on kidney punch.
Musculoskeletal

No deformities and enlarged joints noted

Normal range of motion
No muscle wasting, myalgia, or arthralgia
Neurologic Examination:

Mental Status

Is awake, alert, and coherent

Calm and cooperative, with good eye contact
Responds fully and appropriately to stimuli
Oriented to time, place, and person
Has good insight and fully aware of her condition
Neurologic Examination:

Gait
Is ambulatory, without difficulty in mobility

Coordination
is able to perform rapid alternating movements
without difficulty.
 Neurologic Examination:

Muscle strength: 5/5 on all extremities

Neurologic Examination:

Cranial Nerves
CN I Intact sense of smell.
CN II Pupils equally round and reactive to light and
accommodation
CN III, IV, VI Extra ocular muscle movements intact

V Sensation on face intact. Able to clench teeth, equal

strength on both sides.
Neurologic Examination:

Cranial Nerves

VII Able to raise eyebrows, frown, close eyes, grin,

smile, and puff cheeks.
VIII Acuity good to whispered voice.
IX, X Swallowing reflex intact.
XI Able to raise shoulders.
XII Tongue in midline, without fasciculation, deviations, or
atrophy.
Neurologic Examination:

Sensory System
Light touch intact
Vibration sense intact
Neurologic Examination:

Reflexes: Patellar 2+
Salient Features
 Pertinent Positives Pertinent Negatives
Profile: History:
6 years old (-) pruritic rash
Female (-) diarrhea
(-) constipation
History:
(-) bloody stool
(+) fever
(-) history of allergy to any food or drugs
(+) rash : palpable purpura
(+) edema on both hands and feet
PE:
(+) arthralgia
(-) abdominal distention
(+) abdominal pain
(-) abdominal rigidity
(+) loss of appetite
(-) Rovsings sign
(+) vomiting
(-) Psoas sign
(+) microscopic hematuria
(-) kidney punch
Past Medical History
(+) history of cough and flu
PE:
(+) rash: petechiae and palpable purpura
(+) periorbital edema
(+) right lower quadrant abdominal pain
Differential Diagnosis
 Diagnosis Rule In Rule Out
Appendicitis (+) fever (-) Rovsings sign
(+) abdominal pain (-) Psoas sign
Inflammation of the (+) loss of appetite (-) low grade fever
appendix (+) vomiting
(+) right lower quadrant
abdominal pain

Dengue (+) fever (-) headaches

(+) abdominal pain (-) lymphadenopathy
Is a vector-borne disease (+) loss of appetite (-) pain behind the eyes
transmitted by the bite of (+) vomiting
an infected mosquito. (+) rash Labs to confirm:
(+) right lower quadrant (+) decreased platelet
abdominal pain count
(+) arthralgia
(+) edema
 Diagnosis Rule In Rule Out
Juvenile Rheumatoid 6 years old (+) palpable purpura
Arthritis (+) arthralgia (-) joint stiffness
(+) fever (-) joint swelling
Most common type of (+) rash (-) lymphadenopathies
arthritis in children under (+) edema on feet and
the age of 17. JRA causes hands
persistent joint pain,
swelling and stiffness.

Systemic Lupus (+) fever (-) malar rash

Erythematosus (+) rash: palpable (-) discoid rash
purpura, petechiae (-) photosensitivity
Tissue damage (+) arthralgia (-) oral ulcers
by antibody and immune
complex deposition Labs to confirm:
(+) ANA, decreased
platelet count
 Diagnosis
Idiopathic
Thrombocytopenic Purpura
IgG Antibody develops
against platelet membrane
antigen
Henoch- Schonlein Purpura
Vasculitis characterized by
inflammation of small blood
vessels with leukocytic
infiltration of tissue,
hemorrhage, and ischemia
due to IgA deposits
Rule In Rule Out
(+) rash: purpura (+) fever
(+) arthralgia
Labs to confirm:
(+) decreased platelet count
6 years old Cannot rule out
(+) history of cough and cold
(+) fever * 3 out of 4 criteria for
(+) rash: palpable purpura
diagnosis of HSP has been
(+) edema on both hands and
met
feet
(+) arthralgia: ankles, knees,
wrists
(+) abdominal pain
(+) vomiting
(+) microscopic hematuria
(+) periorbital edema
Impression

Henoch- Schonlein Purpura

Henoch-Schonlein Purpura

Schonlein in 1837 named the association

of joint pain and purpura as purpura
rheumatica
Henoch in 1874 described patients with
purpura, severe abdominal colic, melena
and large joint arthritis
Henoch-Schonlein Purpura

Most common vasculitis of childhood

HSP is considered to be a form of IgA

Nephropathy with extrarenal
manifestations
Epidemiology

Annual incidence of 14-20/100,000 children

worldwide
1.2 1.8: 1 male to female ratio
90 percent occurs between the ages of 3 and 10
Many cases of HSP follow a documented upper
respiratory infection
Pathogenesis

Etiology is unknown
Immune-complex deposition
Inciting agents: URTIs, drugs, foods, insect
bites, immunizations
IgA: the antibody class most often seen in the
immune complexes
Clinical Manifestations

Hallmark: Rash
palpable purpura
symmetric
occur in gravity-dependent areas (lower
extremities) or on pressure points (buttocks)
often evolve in groups
lasts 3-10 days
Rash
Clinical Manifestations

Musculoskeletal

Arthritis and arthralgias, in up to 75%

Arthritis is self-limited and oligoarticular.
Usually resolves within 2 weeks but can recur
Clinical Manifestations

Gastrointestinal

in up to 80%
includes abdominal pain, vomiting, diarrhea,
paralytic ileus, melena, intussusception,
mesenteric ischemia or perforation
Clinical Manifestations

Renal

in up to 50%
manifests as hematuria, proteinuria,
hypertension, frank nephritis, nephrotic
syndrome, and acute/chronic renal failure
Clinical Manifestations

Neurologic

due to hypertension or CNS vasculitis

includes intracerebral hemorrhage, seizures,
headaches, and behavior changes
Diagnosis

American College of Rheumatology Classification

Criteria
Two of the following criteria must be present

Palpable purpura
Age at onset </ 20 yr
Bowel Angina (postprandial abdominal pain, bloody diarrhea)
Biopsy demonstrating intramural granulocytes in small
arterioles and/or venules
Diagnosis

European League Against Rheumatism/ Pediatric

Rheumatology European Society Criteria
Palpable purpura (in absence of coagulopathy or
thrombocytopenia) and one or more of the ff:

- Diffuse abdominal pain

- Arthritis or arthralgia
- Biopsy of affected tissue demonstrating predominant IgA
deposition
Laboratory and Imaging Studies

Common but nonspecific: leukocytosis,

thrombocytosis, mild anemia, ESR, CRP,
occult blood
Autoantibody testing: for exclusion of other
diseases
Assessment of renal involvement is necessary:
BP, urinalysis, serum creatinine
Laboratory and Imaging Studies

Ultrasound: for GI complaints to look for bowel

wall edema or intussusception
Barium edema: to diagnose and treat
intussusception
Biopsy of skin and kidney: often unnecessary,
can provide diagnostic information and show
IgA deposition
Treatment

Supportive: Adequate hydration, nutrition,

analgesia
Steroids (Prednisone 1mg/kg/day): treat
significant GI involvement or other life-
threatening manifestations
Treatment

IV Ig and Plasma exchange: sometimes used in

severe disease
Immunosuppressant: used in some chronic
HSP renal disease
Complications

Serious GI involvement is an acute

complication

Renal disease is a major long-term

complication that can develop up to after 6
months of diagnosis
Prognosis

Excellent, and most children experience an

acute, self-limited course

About 30% of children with HSP experience

one or more recurrences, typically within 4- 6
months of diagnosis