Abstract

Acknowldegement
We wish to express our gratitude to the members of the Pediatrics Department of Vicente Sotto
Memorial Medical Center, to Dr. Camomot, Pedaitric Rheumatologist for providing us the
opportunity to make our case presentation possible.

We would also like to thank resident in charge Dr. Montances; Senior residents Dr. Glaiza S.
Dagani, and to our duty residents Dr. Palermo, Dr. Binoya, Dr. Jinny Jane Yulo for the guidance
and encourgament in carrying out this project.

Finally, to our Almighty God for his never ending grace.

 Table of Contents

Abstract----------------------page 1
Acknowledgement---------------------------page2
Table of Contents------------------------------page3
Introduction-----------------------------------page4
Objective of the Case Report-------------------------------------page5
Significance of the Case Report-------------------------------page6
Case Presentation---------------------------------page7
History--------------------------page7
Physical Examination-----------------------------page8
Differential Diagnosis------------------------------------page9
Course in the Wards------------------------------page10
Discussion-----------------------page11
Conclusion---------------------------page12
References--------------------------------------page13
Appendix--------------------------------page14
INTRODUCTION
 OBJECTIVES OF THE CASE REPORT

The objectives of this Case Report include:

1. To examine the different presentations of Polyarteritis Nodusa according to etiology
2. To discuss the Differential Diagnosis for Polyarteritis Nodusa
3. To discuss the different etiologic agents that can cause Polyarteritis Nodusa
4. To review the current understanding of the normal physiology and pathophysiology of
Polyarteritis Nodusa
5. To examine the diagnostic tools available in Polyarteritis Nodusa
6. To review the current recommended management of Polyarteritis Nodusa
7. To discuss the prognosis of patients with Polyarteritis Nodusa

Significance of the Case Report

The significance of this case is the diagnosis of Polyarteritis Nodusa as a rare disease entity.
Furthermore, Poltarteritis Nodusa is a rarely diagnosed type of vasculitis in childhood and there
have only been 200 pediatric case reports noted in literatures. Arriving at a diagnosis of
Polyarteritis Nodusa comes with a cavet because the clinical course varies widely between mild
disease with few complications to a severe multi-organ disease with high morbidity and
mortality.
 CASE PRESENTATION

General Data:
This is a case of patient JB, 8 years old, female, single, a Grade 2 student, Filipino, Catholic,
born on October 8, 2008 in Talisay City, and is currently residing in Bulacao Talisay City,
admitted at VSMMC on January 11, 2017 for the first time

Prenatal History:
The patient was born to a 25 year old, G1P0. Patient’s mother had her first prenatal check-up at
20 weeks AOG at a Local Health Center by a midwife with regular check- ups thereafter. She
took Ferrous Sulfate beginning at 20 weeks AOG. No other medications were taken during the
pregnancy. Laboratory workup and ultrasound were done with unremarkable result. Patient’s
mother noted to have Urinary Tract Infection diagnosed at 20 weeks AOG and was prescribed
with Amoxicillin 500 mg taken twice a day in seven days. She is a non smoker, non alcoholic
drinker and denies use of illicit drugs.

Natal History:
Patient was born term, delivered via NSD, at VSMMC. The patient was noted to have a good
cry at birth with a birth weight of 2800 g. No history of perinatal complications were noted.
Duration of stay at the hospital was 48 hours.

Feeding History
Patient was exclusively breastfed from birth to 3 months. Mix feeding with Formula milk (BONA)
was started thereafter with a ratio of 2 scoop to one glass of water. Soft food such as Cerelac
was started at 8 months old. Solid food was introduced at 12 months. Weaning began at 12
months. Currently the patient has good appetite. Her diet comprises mostly of salty and
processed foods and occasionally of fruits and vegetables. She drinks one glass of water in a
day. She is also fond of drinking soft drinks.

AGE TYPE OF FEEDING

Birth to 3 months Exclusive breastfeeding

4 months to 7 months Mixed feeding w/

formula milk (BONA)

8 months Soft food (CERELAC)

1 year Solid food (RICE)

Growth and development:
Patient growth and development was at par with age in all aspect of development.

GROSS MOTOR

3 mos holds up head

4 mos sits with support, rolls over

1 yr old walks unaided

15 mos walks well

2 yrs runs well, goes up and down the stairs, jumps both
feet

FINE MOTOR SKILLS

6 mos passes objects between hands, grasp

toys

LANGUAGE

6 mos babbles

10 mos. says mama-dada

PSYCHOSOCIAL HISTORY

2 mos social smile

14 mos starts using utensils

18 mos plays with others

Immunization history:
Patient had 1 dose of BCG and Hepatitis B vaccination at birth, 3 doses of DPT, OPV at 6,10,14
weeks, and 1 dose of MMR at 1 year old, all given at a local health center.

1st dose 2nd dose 3rd dose

BCG 

DPT   

OPV   

Hep B   

Pneumococcal

Rotavirus

MMR 

Past Medical History:

Patient was noted to have Varicella zoster infection at 5 months.
No history of previous hospitalizations, chronic illness, trauma, nor surgery noted. No known
food and drug allergies were noted.

Family History:
Parents are apparently well.
Heredofamilial disease includes Diabetes mellitus and Arthritis in the maternal side.

PLEASE INSERT FAMILY PEDIGREE

Personal and Social History:

Patient is a Grade 2 student, birth rank of 1/1. Patient claims to be playful with friends and
performs well in school. She lives with her grandmother, uncle, aunt and one cousin. Her single
mother works in manila as a maintenance worker. They live in a one story semi-concrete
house, with running water, toilet and electricity. Source of drinking water is tap water and
occasionally mineral water. Her grandmother prepares for her food everyday.
History of Present illness:
Six days prior to admission, patient was noted with intermittent undocumented fever. Patients
condition was associated with pain on both upper and lower extremities characterized as dull
pain (PS 6/10) and multiple palpable soft nontender movable nodules with an estimated size of
2x2 cm in both lower extremities. No other associated symptoms noted such as headache,
dyspnea, cough and colds, nausea and vomiting, hematuria, abdominal pain, rashes. Patient
self medicated with Paracetamol 250mg/5ml 1 tbsp (5ml) taken twice daily but afforded
temporary relief. No consult done and condition was tolerated.
One day prior to admission, patients condition persisted with an onset of swelling of both lower
and upper extremities characterized as pitting edema. Patients condition was associated with
bilateral lower extremity weakness. No other associated symptoms noted such as headache,
rashes, abdominal pain, dyspnea, change in bowel movement, dysuria, nausea and vomiting.
Consult was done and was referred in this institution for further management.
PHYSICAL EXAMINATION
General Survey
• Patient was seen awake, conscious & not in respiratory distress. Her appearance is
appropriate for age.

Vital Signs
• BP: 100/70 mmHg, left arm, sitting
• HR: 140 beats per minute, regular
• RR: 24 cycles per minute, regular
• Temp: 37.8 °C
• O2 sat: 99%

Weight: 23kg
Height: cm
BMI:

Skin
Inspection: brown complexion, no peripheral or central cyanosis, no jaundice
Palpation: dry and rough, warm to touch, no edema

Skull
Inspection: normocephalic, no deformities
Palpation: closed fontanels, no areas of tenderness, no depressions noted

Eyes
Gross External Exam
Eyebrows: black in color, hair equally distributed
Eyelids: no nodules, no lesions, no lidlag, no ptosis
Conjunctiva: pinkish palpebral, no lesions
Eyelashes: black in color, equally distributed, no ectropion or entropion, no scales
Sclera: white, no ulcers, no protrusions
Cornea: transparent, no ulcers
Lens: clear, transparent, no opacities
Pupils: equally round about 4mm in diameter, equally reactive to light and accommodation
Light reflex: (+) direct and consensual light reflex on both eyes
Visual Acuity : 20/20
Extraocular movements: patient can move eyes in all direction, no eye muscle paralysis
Tonometry: soft, no signs of increased intraocular pressure
Fundoscopy: (+) ROR, clear media, no hemorrhage, no exudates, no infiltrates

Ears
Auricle: no deformities, no masses, non-tender
Ear Canal: wet earwax noted, no impacted cerumen, no foreign body seen
Ear Drum: visible tympanic membrane, pearl-gray in color, non-perforated, non-retracted, non-
bulging

Nose
Inspection: symmetrical; septum is midline, no nasal obstruction, no discharge
Palpation: no tenderness of nasal tip

Neck
Inspection: no distended veins noted, no masses
Palpation: thyroid not enlarged, trachea at midline, no lymphadenopathy

Mouth/Throat
Lips: dry, cracked lips
Tongue - pink, midline upon protrusion, mobile, no masses noted

CHEST AND LUNGS

Inspection: no chest deformity, no asymmetry, no retractions/ chest indrawing
Palpation: no tenderness, equal and good chest expansion
Percussion: resonant sound elicited on both lung fields
Auscultation clear breath sounds on both lung fields

Cardiovascular
Inspection: adynamic precordium
Palpation: apical impulse located 7 cm from midsternal line, small in amplitude, brief in duration
Auscultation: distinct heart sounds, no murmurs

Abdomen
Inspection: protuberant, spider angioma on periumbilical area, no rashes
Auscultation: absent bowel sounds
Percussion: dullness on all quadrants
Palpation: (-) fluid wave test

Extremities:
Inspection: no deformity, no swelling, no change in color, no muscle atrophy on all joints; no
clubbing and no cyanosis
Palpation: warm, no tenderness; brachial, radial, ulnar, femoral, popliteal, dorsalis pedis,
posterior tibial pulses felt; no swelling, capillary refill time <2 seconds

Tanner Stage

Females Males
Tanner Stage
Breast Pubic Hair Genitalia Pubic Hair

1 Nipple elevation none Testicles 1-2 cm None

only

2 Small raised Growth along Testicles >2cm, Sparse, lightly

breast bud labia, sparse, scrotal pigmented
lightly pigmented enlargement

3 Breast and Increases in Testicles Increases in

areola enlarge amount, continue to amount, darkens
with contour darkens, starts to enlarge, penis starts to curl
difference curl lengthens

4 Further Resembles adult Scrotum darkens Resembles adult

enlargement with type, but not widening of type, but not
areola and nipple spread to medial glans penis spread to medial
projecting to thighs thighs
form secondary
mound

5 Adult contour Spreads to Adult size and Spreads to

with areola and medial thighs morphology medial thighs
breast in same adult distribution adult distribution
contour nipple
protruding
Neurologic Examination
A. Mental status exam
Patient was awake, responsive, comfortable, normal posture and active. Appropriate facial
expression and apprehensive. Oriented to time, date person, intact recent and remote memory.

B. Cranial Nerves
I – can distinguish the smell of foods
II- (+) direct and consensual pupillary light reflex
III, IV, VI – intact EOM, (+) pupillary constriction, no ptosis
V – (+) temporalis and masseter muscle contraction, (+) corneal reflex
VII – (+) facial expressions, able to smile, pout, frown, no facial paralysis, no abnormal
movement
VIII – able to hear whispered words on both ears
IX, X – no hoarseness of voice, no vocal paralysis, soft palate rises, no atrophy or
deformities, (+) gag reflex
XI – can shrug shoulders with resistance, symmetrical neck
XII – no deviation when tongue protruded, no atrophy
C. Motor System
Normal posture, no abnormal swaying, no loss of balance, normal muscle size, no
involuntary movements, no tremors, no spasticity, normal resistance, no ataxia

D. Sensory Exam
Able to feel pain on both sides of the body, can sense light touch and distinguish hot
from cold
Meningeal Signs
(-) Brudzinki Sign
(-) Kernig Sign