1801006013 Long case

 13 year old female student from suryapet came to the OPD with chief complaints of

Vomitings on Monday night

breathlessness since 1 day 

History of present illness:

Patient was apparently asymptomatic before 2020

Then she Developed multiple swellings in the neck bilaterally,no pain, firm in consistency,  7 to 8 in number.

She also had fever insidious, intermittent, no night rise of temperature, relieved with medication  dolo 3 tid

She also had cough ,dry cough, non productive, no hemoptysis ,relieved with medication from rmp (cough syrup).

She had all these symptoms for 2 to 3 months 

They consulted rmp and he gave them medication probably att because her mother has tuberculosis 

Swellings size decreased and symptoms were relieved.

But the fever was progressively increasing despite regular treatment so they told rmp about it and stopped it.

And rmp suggested them to go for checkup in hospital and they went to hospital in Hyderabad and got tested (fnac,cancer tests, tb tests, mantoux, sputum culture, cbnaat)because her mother is a known case of tuberculosis. 

And got admitted for 10 days and recieved symptomatic treatment 

(She also had complaints of joint pains wrist and knee)

They suspected it to be automimmune and started her on Hcq and wysolone tab which they used for 15 days. 

ANA ELISA equivocal

ANA IFA negative 

ANTI DS DNA ELISA positive

ANTI DS DNA IFA negative

She went back home 

In June 2022 she started developing pigmentation/rash over face which then was seen on scalp evident because of hair loss and on trunk since 3 months,not associated with itching.

And also pedal edema upto ankles which then progressed till knee in the last 3 months,pitting type.

Then she was taken to area hospital and got tested and the attender(father) was informed that she has tuberculosis. 

Ln biopsy was done

Mycobacterial gene expert test was done 

No reports available

So they started her on ATT and recieved regular treatment for 6m.

Her symptoms settled and she was fine until January 10 when she develop edema again (generalized)

They went to another hospital and got tested and was told to have proteinuria.

In January and February she had mild fever and 

1 week back she developed fever and edema again.

On 13 March she had episodes of vomiting 4 episodes ,food as contents,non bilious, with gap of approx 1 hr between episodes.

She also developed sob grade 2 and they got her to kmni. At 5.30 -6 am.

In 5th class her weight was 28kgs then in 6th class 23kgs,8th class 21 kgs

After att treatment her weight got improved to 23kgs that is last year

In December 26kgs, 24kgs ,yesterday it was 25kgs.

Past history 

K/c/o tuberculosis 

Not a known case of diabetes, hypertension, epilepsy, thyroid

Treatment history :

Used ATT for 6 months for TB

Personal history :

Single 

Student

Daily routine:

She studied in local school until 4th class 

In 5th she went to gurukul school and joined in hostel

And the she was fine until 6th

During 7th class she started having these symptoms

After 7th she stopped school as it got worse and she was frequently visiting hospitals.

She went to hostel again after her att treatment and subsidence of symptoms in dec.

Was fine until January and she came back home again . 

In hostel previously :

5 am  wake up

Gets ready by 6 am

6:30 am to the ground for yoga,exercises 

7 am ragi Java

7.30 am prayer 

8am classes 

9.15 am breakfast 

Classes until 1.30

1.30 to 2.30 lunch

2.30 to 4.30 study hour

4.30 to 5 snacks

5.00 to 6 pm walking ,playing 

6 to 6.30 prayer

7 pm dinner

Till 9 pm study hour

9pm sleep 

At home :

6am wake up

7 am tea

Breakfast and fruits 

Tablets 

Sleeps until afternoon

2.30 to 3 lunch

2 months after taking ATT her appetite was increased and she ate more food ,more frequently (5times a day).

Walking exercises 

Eve 6pm fruits

Songs prayers

8pm dinner

9pm sleep 

Personal history:

Diet mixed

Appetite normal

Bowel bladder movements oliguria, bowel normal

Sleep decreased

Addictions none

Family history

Mother was diagnosed with TB in 2014 and 

Used ATT irregularly

She used att when she had symptoms for 1 to 2 weeks

And stopped after symptoms subside

Symptoms got worse in 2022 and she died in sept 2022

Birth history:

1st born child

2nd degree consanguineous marriage

Lscs

Father has no idea about immunisation status

Menstrual history 

Not attained menarche yet

General examination:

Patient is conscious coherent and cooperative 

Well oriented to time place. And person

Patient examined in well lit room

Pallor present

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Edema present

Vitals

On 14\3\23

Bp 130\80mmhg 

Pulse rate 110 bpm

Regular, normal volume

Respiratory rate 32 cpm

Sp02 99%

On 15\3

Bp 130/90 mm hg

Respiratory rate 26cpm

Pulse rate 120bpm

Temperature afebrile

Sp02 98%

systemic examination:

Abdominal examination

Shape - slightly distention.

Umbilicus  - Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.

Palpation

soft, tenderness in right and left Hypochondrium, epigastrium.

Percussion

Fluid thrill and shifting dullness present

Auscultation

Bowel sounds heard

No bruit or venous hum.

Respiratory examination

Bilateral air entry present

Dull note

Vocal resonance decreased

Cvs examination

S1 s2 heard, no murmurs

CNS examination

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal sensations

Motor examination normal

Reflexes normal

Investigations

Spot urine sodium 166mmol/l

Spot urinary potassium 20.5

Abg

pH 7.4

Pc02 14.9 mm hg 

P02 79.8mm hg

Hc03 9.2 mmol/l

O2 saturation 96%

Serum electrolytes on 14\3

Sodium 136 meq/l

Potassium 4.4 mEq/l

Chloride 106 meq/l

Serum creatinine 0.6mg/dl

Esr 70 mm

CRP neagtive

Blood urea 29 mg\dl

FBS 100 mg\dl

Blood group 0+

Rheumatoid factor negative

HIV non reactive

Hbs ag non reactive

Urine examination:

Colour pale yellow

Appearance clear

Acidic

Specific gravity 1.010

Albumin ++

No sugar, bile salts, bile pigments, rbc, crystals, casts, amorphous deposits

Pus cells 3 to4 \hpf

Epithelial cells 2 to 3 \hpf

On usg

Liver,gallbladder,pancreas,spleen, uterus,ovaries normal

Moderate ascites

Bilateral pleural effusion

Moderate pericardial effusion

Bilateral grade 2 rpd change

Hb 7.5 g\dl

WBC 4200 cells\cumm

Neutrophils 60

Lymphocytes 36

Eosinophils 02

Monocytes 02

Basophils 0

Pcv 24.6 vol%

Mch 76.4 fl

Mchc 30.5%

Rdw 20.6 %

Rbc count 3.2 million\cumm

Platelet 1.57 laksh\cumm

Smear normocytic normochromic anemia

On 15\3

Serum creatinine 1.0 mg\dl

Sodium 1.37 meq\l

Potassium 4.7

Chloride 104

Spot urine protein 393 mg\dl

Spot urine creat 37.8 mg\dl

Ratio 10.3

Used 4 tablets per day for 6 months regularly. 

Provisional diagnosis

?Automimmune disease

Glomerulonephritis secondary to lupus 

Treatment

Fluid restriction 

Salt restriction

Inj lasix 40mg IV BD

Inj monocef 1gm IV BD

Inj Methyl prednisolone 250mg in 100ml NS IV OD

Tab Aldactone 25mg  PO OD

Tab shelcal 500mg PO OD

Vitals monitoring