Практикум по педиатрии. Practicum in Pediatrics. Учебное пособие для студентов 5-го курса

2.Rate changes in the urine and the state of concentration and filtration functions of the kidneys.

3.What is the pathogenesis of the disease in this patient?

4.What is the strategy for further investigation?

5.Assign treatment.

6.Which are outcomes of this disease? Can it disappear spontaneously in this case?

Case 5

A boy of 7 years old admitted to the hospital with complaints of headache, loss of appetite, swelling on his face and a decrease in urine output.

Birth weight 3,100 g, length 51 cm. Development of the child is normal. Vaccinations were according to the calendar. Diseases: chicken pox, upper respiratory viral infections rare.

Two weeks ago suffered angina. He was treated at home, amoxicillin for 5 days, symptomatic therapy included gargling of throat by soda solution, the treatment showed improvement. Before hospitalization the child had pain in the lumbar region, his mother noticed that he began to urinate less often than usual, and in the evening there was darkening of the urine, the color of "meat slops". In the morning there was edema of the eyelids. In urinalysis: protein – 1.32 g/l, WBC – 10-12, RBC – all over.

On examination: the boy's condition is moderate. He complains of headache and weakness. Edema of the eyelids, pastosity of legs and hips is noticed. Skin is clean. BP – 125/95 mm Hg. Auscultation of

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the heart: muffled sounds, HR 110 per min. The abdomen is soft on palpation. Diuresis for one day was 500 ml.

CBC: Hb – 115 g/l, Ht – 23, RBC – 3,0х1012/l, WBC – 10.1х109/l, stab – 3%, segment – 75%, eosinophil – 2%, lymphocytes – 21%, monocytes – 7%, ESR – 27 mm/hr.

Urinalysis: glucose absent, protein – 1.2 g/l, WBC – 7-10, RBC all over.

Zimnitskiy's test: daytime diuresis 1/3 nocturnal diuresis, relative density 1010-1025.

Biochemical test of blood: total protein – 65 g/l, Cholesterol – 4,1 mmol/l, albumin – 53%, α1-globu-

Reduced levels of C3, C4 – complement.

Questions:

1.Your clinical diagnosis? Formulate the diagnosis in accordance with modern requirements.

2.Which investigation can confirm the etiology of this disease?

3.What is the pathogenesis of the disease?

4.Diagnostic criteria of oliguria and anuria in children. Explain the pathogenesis of oliguria and proteinuria.

5.Which changes in the blood coagulation system can be observed in this child?

6.Assign treatment.

7.Prognosis of the disease.

8.How could this disease be prevented earlier?

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Case 6

A patient of 6 years old was admitted to the hospital on the third day of illness with complaints of headache, swelling of the face, legs, the appearance of the urine in the form of "meat slops". Early child’s development was without specific features, heredity is not burdened.

Since the age of 5 years he has had frequent viral respiratory infections, chronic tonsillitis.

The present illness began 2 weeks after upper respiratory virus infection.

On examination: the child’s state is moderate. Skin and visible mucous membranes are normal color, clean, swelling of the face, pastosity of legs and feet. Cardiopulmonary functions are normal. Blood pressure 130/85 mm Hg. Abdomen is of normal shape, soft, painless on palpation. Liver is not enlarged. The kidneys are not palpable, Pasternatsky's symptom slightly positive on both sides. Urine is red. Diuresis per day is 500 ml.

CBC: Hb – 125 g/l, RBC – 4.3х1012/l, WBC – 12.3х109/l, stab – 5%, segment – 60%, eosinophil – 5%, lymphocytes – 24%, monocytes – 6%, ESR – 20 mm/hr.

Urinalysis: color – red, transparency – incomplete, reaction – alkaline, relative density – 1023, epithelium – 1-2, RBC – all over, WBC – 2-3, granular cylinders – 3-4, protein – 0.99%. Daily loss of protein 1.6 g/l/day.

Nechiporenko's test: WBC – 250, RBC – 4000, cylinders 2000.

Addis-Kаkovskii urine test: RBC – 3 mill.

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Biochemical test of blood: total protein – 69 g/l, Cholesterol – 6.0 mmol/l, urea – 17.2 mmol/l, creatinine – 187 mmol/l, sodium – 141 mmol/l potassium – 5.2 mmol/l.

Ultrasound: liver, gallbladder, pancreas, spleen without pathology. Kidneys are in their typical localization, their size is not increased, parenchyma is not changed. Pyelocaliceal system has normal structure.

Questions:

1.Formulate detailed clinical diagnosis and jus-

tify it.

2.Explain appearance of cylindruria in the urine. Which types of cylinders in the urine are abnormal?

3.Explain the appearance of red blood cell in the urine. Which kinds of hematuria do you know?

4.What causes blood pressure increase in this form of disease?

5.Differential diagnosis of hypertension in chil-

dren.

6.Which complications are possible in this form of the disease, name their clinical manifestations.

7.Which diet should be appointed to this child?

8.Assign treatment.

Case 7

A 9-year-old boy suffers from food and drug allergies, frequent viral respiratory infections. He suffered from influenza A, and then, on the 20th day,

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appeared paleness, edema of the eyelids in the morning, fatigue, loss of appetite, headache. Urine test revealed RBC 10, protein 1.0%, the child was hospitalized with diagnosis "acute nephritic syndrome". During one week, despite ongoing therapy, his condition did not improve, weakness was growing, urine color was like "meat slops", swelling of the legs, blood pressure 100/67 mm Hg., azotemia appeared. Further, renal biopsy was performed; morphological pattern matched extracapillary nephritis with 55% "demilune". Immuno-suppressive therapy was assigned (prednisone, cyclophosphamide). After treatment, the child’s condition stabilized. The condition deteriorated after 1 month, when the child had respiratory virus infections again. Swelling appeared on the face and legs.

On examination in the hospital: (the third month from the beginning of glomerulonephritis) height is 130 cm, blood pressure 150/100 mm Hg. Diuresis per day is 750 ml, protein 180 mg (norm – 200 mg/l).

CBC: Hb – 90 g/l, ESR – 37 mm/hr.

Urinalysis: relative density – 1007, protein – 0,43‰, WBC – 10-15, RBC – 50-60, epithelial and erythrocyte cylinders 3-8, fat.

Nechiporenko's test: WBC 2750, RBC 92000, cylinders 700.

Zimnitskiy's test: 1004-1008, nocturia. Biochemical test of blood: total protein – 60 g/l,

albumin– 35 g/l, urea – 14.5 mmol/l, creatinine – 248 mmol/l, sodium – 144 mmol/l, potassium – 7.2 mmol/l, phosphorus – 2,2 mmol/l. ASLO titer is not elevated.

Coagulogram: High levels of fibrin in the blood. Acid-base balance: pH 7.24, BE – 13.

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Questions:

1.Put diagnosis and justify it.

2.Classify inflammatory glomerulopathy depending on the period of the disease? Name possible outcomes of glomerulopathy.

3.Which diseases can lead to rapidly progressing nephritic syndrome?

4.Which cases of acute nephritic syndrome require biopsy?

5.Which sizes of kidney will the ultrasound examination show in this case? How will the size of the kidneys change in the different stages of CKD?

6.Treatment, feathers of diet.

7.Prognosis of this disease.

Case 8

A boy of 4 years old was admitted to the hospital with complaints of weakness, poor appetite and swelling.

Anamnesis: physical and psychological development according to the age. Heredity history is not burdened. The child became ill 17 days after upper respiratory virus infection. There was edema, lethargy, pallor. Within a month, swelling grew; diuresis was 500 ml per day.

On admission: the child’s state is moderate. BP 95/45 mm Hg. HR – 82 per min. Weight 23 kg, height 107 cm. Skin is pale. There is severe swelling of the face, legs, feet, anterior abdominal part and lumbar region. Borders of heart: right – on the right edge of sternum, left – one on the left midclavicular line.

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Heart sounds are muffled. The abdomen is soft, painless on palpation. Liver +2 cm, spleen is not palpable. Diuresis per day is 300 ml.

CBC: Нb – 160 g/l, RBC – 5,2х1012/л, WBC – 9,8х109/л; stab – 3%, segment – 36%, eosinophils – 7%, lymphocytes – 52%, monocytes – 2, ESR – 37 mm/hr.

Urinalysis: color – yellow, relative density – 1028, reaction – neutral, protein – 6.0 g/l, WBC – 0-1, RBC – 0-1, epithelium and bacteria – a little.

Zimnitskiy's test: day volume = night volume, relative density 1013-1028.

Biochemical test of blood: total protein – 47 g/l, protein fractions: α1 – 4, α2 – 14, β – 18, γ – 17; cholesterol – 16 mmol/l, potassium – 3,81 mmol/l, sodium – 137.5 mmol/l, urea – 5.1 mmol/l, creatinine – 59 mmol/l, values of triglycerides and β-lipoproteins are high. Glomerular filtration rate 99 ml/min/1.73 m2.

Coagulogram: fibrinogen – 4.5 g/l, prothrombin – 130%.

Biochemical test of urine: protein – 3,5/day. Renal ultrasound: kidneys are located in typical

place, increased in size, echogenecity of cortex diffusely decreased moderately.

Questions:

1.Put diagnosis and justify it, assess the renal function.

2.Explain the genesis of edema syndrome in this disease.

3.Differential diagnosis of edema.

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4.What will be revealed during examination of eye fundus in this child?

5.Diet and water regime in this disease.

6.Can diuretics be the only drug in treatment of this patient?

7.Make a plan of treatment.

8.What are the possible complications?

Case 9

A boy of 12 years old. Anamnesis: at the age of 9 years, after acute respiratory infection, urine was red within 5 days, protein 0.2%, RBC 30-40, erythrocyte cylinders and oxalate salt. Heredity history is not burdened.

Over the next 3 years hematuria has been observed repeatedly, usually associated with respiratory virus infection, UV irradiation, heavy physical exertion. Edema around the eyes was not observed, proteinuria was not more than 500 mg/l/day. Blood pressure is 120/85, once there was an increase up to 130/90 mm Hg, after that, another episode of macro hematuria appeared. At the age of 12 years biopsy was performed, which showed an increase in cells and extracellular matrix and accumulation of IgA in the mesangium.

Nechiporenko's test: WBC 1000, RBC 7000. Biochemical blood test: Creatinine – 65 mmol/l,

electrolytes vales are normal, total protein – 70 g/l, slight decrease of albumin and increased of α2- and γ-globulin, cholesterol, lipoproteins are normal.

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IgA levels in serum 3.8 g/l (normal 0.4-3.5 g/l). Contents of component C3 is normal.

Daily loss of protein: 260 g/l/day.

Questions:

1.Put full clinical diagnosis.

2.Justify the diagnosis.

3.Differential diagnosis of "recurrent hematuria".

4.Prognosis of renal function?

5.Can we assume the observed increase in blood pressure in this child as an unfavorable course of the disease?

6.Assign the diet and treatment.

Case 10

A 9-year-old boy was admitted to the hospital with complaints of headache, swelling, discoloration of urine (color "meat slops").

Anamnesis: birth weight 3,500 g, height 54 cm. Up to 6 years development was according to the age, had chicken pox, upper respiratory virus infections (URVI) – 3-4 times a year, there was a reaction to DPT vaccine, food allergy, drug allergy to antibiotics (penicillin). During the last 6 months concerns about impaired vision appeared. Heredity: his mother has asthma, atopic dermatitis, his grandfather has hypertension.

He became ill at the age of 6 years. The disease appeared 2 weeks after respiratory virus infection: there appeared edema, oliguria, proteinuria, red

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blood cells in urine, anemia; blood pressure was 150/90. After the treatment, including prednisone, his condition improved, clinical and laboratory remission was observed. Further sometimes in urine tests were revealed RBC 3-4 and protein up to 0.5%. Diuresis was 2 liters (clear urine), complained of thirst.

Current exacerbation began after URVI. The boy was admitted to hospital in serious condition. On examination: height 120 cm, “moon-like face”, there is swelling of the lower back, abdomen and legs. In the lungs there is vesicular breathing, no wheezing, RR – 28 per minute. Heart sounds are muffled; borders are expanded, systolic murmur at the apex. HR 92 per min, BP – 150/100 mm Hg. Diuresis 350 ml/day. The abdomen is soft, painless on palpation. Liver +3 cm, spleen is not palpable.

CBC: Нb – 95 g/l, Er. – 3,2х1012/l, color index – 0,9, WBC – 6,5х109/l, stab – 8%, segment – 66%, Eosinophils – 1%, Lymopcytes – 19%, monocytes – 5%, ESR – 56 mm/hr.

Urinalysis: color – brown, reaction – alkaline, relative density 1002-1003, protein – 1.6%, white blood cells – 3-5, red blood cells – all over, granular cylinders.

Zimnitskiy's test: daytime diuresis = 1/3 nocturnal diuresis, variations in relative density 1002-1012.

Biochemical test of blood: total protein – 50 g/l, albumin – 50%, globulins: α1 – 3.7%, α2 – 12%, β – 9.9%, γ – 24.3%; cholesterol – 12.37 mmol/l; potassium – 6.0 mmol/l; sodium – 144 mmol/l; phosphorus 1.8 mmol/l, urea – 8.4 mmol/l; creatinine 90 mmol/l; Glomerular filtration rate 53 ml/min/1.73 m2.

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