Hey guys, thanks for the input so far, theres some new information, so Ill compile my first post with the rest so that you would get a clearer picture.
A 10 year old girl, presented with shortness of breath for 1 day, aggravated by physical activity, relieved by resting. Physical examination was positive for pleural effusion, but there was also gross ascites and hepatomegaly, approximately 3 cm below the coastal margin, non tender. There was no splenomegaly, lymph nodes were not palpable, examination of the other systems were unremarkable.
A CXR was done which showed a massive right sided pleural effusion (no mass seen).
For the LFT:
Total protein: 73 g/L (normal)
ALP: 204 u/L (raised)
GGT: 71 u/L (raised)
ALT, albumin, globulin, total bilirubin both direct and indirect are all normal.
Mantoux test: Negative
ANA: negative
Urea and Creatinine: Normal
Na, Mg, Phos etc: All normal
Pleural fluid: Total protein: 37 (low), LDH: 159 (normal), after calculating the ratio, it is shown to be transudative in nature.
Ultrasound of the abdomen and pelvis (as recommended):
Enlarged liver of 15 cm, homogenous with normal parenchyma, other abdominal structures including the gall bladder (including common bile duct), spleen, kidneys are normal. Uterus normal in size, unfortunately, the ovaries could not be seen (Cant rule in/out Meigs syndrome). Gross ascites seen, no focal lesion seen in abdomen and pelvis.
Her plan of investigation for tomorrow would be a TFT, serum amylase and Hep B screen.
*********Now, the interesting additional bit.
About a month ago, she came in with facial puffiness for 1 week, SOB, periorbital swelling, abdominal distension, fever for 2 weeks associated with chills and rigors, she claimed to have tea colored urine. There were multiple old impetigo skin lesions over both lower limb, throat was inflamed and tonsils were enlarged but there were no exudates. There was ascites, hepatomegaly and a massive right sided pleural effusion during this admission as well. Vital signs were normal, no hypertension.
Urine examination and microscopy:
Albumin 2+
Negative glucose
Pus cells 4-6
RBC 1-2
Granular casts seen
CBC: Normal
Serum electrolytes, urea, creatinine: Normal
ASOT: Normal
ESR: Normal
Urine culture and sensitivity: No growth
Throat swab: Klebsiella pneumonia cultured
C3: 1.96, slightly raised (normal 0.9-1.8)
C4: 0.23, normal (normal 0.1-0.4)
24 hour protein: 0
She improved clinically and was discharged after 9 days with the diagnosis of acute glomerulonephritis complicated with right pleural effusion and ascites. Her medication on discharge was oral Frusemide and Oral Unasyn (Sulbactam & Ampicillin).
************
My thoughts so far, during the first admission, she would not have nephritic nor nephrotic syndrome.
Suggestions of a parasitic infection, the CBC has normal WBC levels with a predominance of neutrophils.
There was no history of travel and no one in her family presented similarly.
The patient and her family members claimed that for a 10 year old, she did not take any drugs/alcohol.
Meigs Syndrome is still possible, too bad the ovaries could not be seen.
I suggested a diagnostic paracentesis but the pediatrician said that the contents of the pleural fluid would be likely to reflect that of the ascitic fluid so it was unnecessary.
As noted earlier on, her plan of investigation for tomorrow would be a TFT, serum amylase and Hep B screen.
She is scheduled for a CT thorax soon.
I was thinking of adding on a rheumatoid factor, and since were doing Hep B screen, why not include everything right? It was pretty tough to draw blood from this kid so it would be good to take as many as possible.
The labs refused a dsDNA since the ANA was negative.
She does not have Cushingnoid features, looks pretty normal, shes tolerating orally, currently afebrile, vitals are all within normal range.
If there was leukemia or lymphoma, I would expect her CBC parameters to be worse but they are not.
No SLE features as well, went through the whole list of vasculitis and none fits.
Not too sure if the parents are keen on a liver biopsy with only ALP and GGT raised.
The renal profile and urine analysis looks good as well, these tests were all repeated to make sure there was no error and on different machines, thus, if I would like to suggest a renal biopsy, I would have to have a pretty good reason for it.
Currently, no one knows whats wrong with her, so shes just on IV Frusemide, supplemental oxygen and we tap about 15 ml of pleural fluid everyday.
My plan of investigation for tomorrow would be the TFT, serum amylase, Hepatitis screen, rheumatoid factor, and if nothing, extend the CT thorax to include the abdomen and pelvis as well.
Would it be dangerous to start her on low dose steroids and see how she responds?
So, we have to do with what we have..
Totally missed that. I was like, "why isn't she at CHOP already?". It's cool that we can communicate across the seas like this! Are all Malaysians schooled on English or are you just particularly adept?
