ANASARCA

Case
Presentation
IDENTIFYING DATA
Name: J.
Age: 8 y/o
Sex: male
Address: Siit Luuk, Sulu
Civil status: single
Religion: Islam
Ethnicity: Tausug
Date of Admission: Feb. 18, 2016
Source of information: father and
grandmother
Reliability: 80%
Chief complaint:

GENERALIZED EDEMA
HISTORY OF PRESENT ILLNESS

The edema started approximately one (1) month ago,

first observed in the abdomen then became
generalized with no alterations in his physical
activities and appetite noted. Ten (10) days prior to
consult, the patient became weak and cant anymore
sit. He had abdominal pain as well as difficulty in
defecating. He had oliguria, void urine once per day
only. The urine is described as dark yellow, turbid, and
frothy. There was no associated fever, dysuria,
cough, gross hematuria and blood in feces.
He was brought to albularyo and leaves of
plants were applied, superficially, to his
abdomen. After that, there was appearance of
maculopapular rash on the abdominal area. He
was also hospitalized in Bongao and was referred
to ZCMC.
GROWTH AND
DEVELOPMENT MILESTONE
 2 months raised head from prone position,
started to smile
5 months started to roll over, grasps object
placed in hand, moves head towards sound
6 months no head lag
7 months started to sit with support, started
to feed self with crackers
9 months started to sit without support, mah,
nah
 12 months started to stand with support,
thumb finger grasp, walks halding on
14 months stand without support, throws toys
20 months walks well alone, drinks from cup
24 months runs well, speaks three words in a
sentence, points to one part of the body
3 years started to ride on a tricycle, throws
balls
PAST MEDICAL HISTORY
The patient was born via spontaneous vaginal
delivery, attended by a hilot at their residence
in Sulu. There was no immunization done.
There was no prior hospitalization and previous
surgeries. He experienced occasional asthma-
like attacks prior to the appearance of edema.
He was breastfed and shifted to semisolid foods.
The usual diet of the patient includes rice, fish
and cassava. He started to walk without
support at 2 years old and speak
comprehensively at 4 years old.
FAMILY HISTORY

There was no hypertension and diabetes in

the family.
PERSONAL AND SOCIAL
HISTORY
The patient lives with his family. There are eight
members of the family. His five siblings have no
edema and other diseases. No one smokes or
drinks liquor within his family. Their source of
water came from a deep well near their house.
Their food source came from their own backyard
and sometimes from the market near their
place. His mother is the one who prepares their
meal. The family does not practice
handwashing often. Their house is made of light
materials. They have their own flush-type toilet
facility. They have their own culture and belief
that hinders them to seek medical care from the
barangay health center, which is approximately
5 kilometers away from their home.
REVIEW OF SYSTEM
 General: the patients father and grandmother
noticed a big difference in his weight. His clothes
are now too tight and his shoes dont fit anymore.
The patient is now more irritable than before.
Skin: the patients father noticed the appearance of
rash in the abdomen and inguinal area days prior to
admission.
HEENT: there is no history of discharges from nose,
ears and mouth. He does not experience any
lightheadedness, vision changes, difficulty of
hearing, nasal stuffiness and difficulty of
swallowing.
 Neck: The patient experiences pain and
stiffness in the neck due to his
immobilization.
Breast: The patient does not have any
discomfort, and any nipple discharges.
Respiratory: no history of cough, hemoptysis
and hematemesis. The patient seldom
experience difficulty in breathing.
Cardiovascular: no chest pain or discomfort
and palpitations
 Gastroinestinal: good appetite, no history
of blood in stool, diarrhea; vomited after
inserted with IV line
Peripheral Vascular: The patient
experienced swelling of his extremities.
He does not experience any intermittent
claudicating, leg cramps, past clots in
vein, color changes in fingertips or toes
during cold weather.
Urinary: The patient experienced change
in his urination pattern he voids less
frequently and his urine is frothy.
 Genital: the patient experienced swelling of his
penis shaft days prior to hospitalization. He
does not experience any penile discharges and
no history of sexually transmitted infections.
Musculoskeletal: He frequently experiences
generalized stiffness and muscle and joint pain.
Psychiatric: The patient feels positive about the
outcome of his treatment.
 Neurologic: The patient is coherent, does not
have headache, or any involuntary
movements.
Hematologic: The patient does not have any
bleeding tendencies.
Endocrine: he does not experience heat or
cold intolerance and excessive sweating. But
the patient experienced oliguria and recent
change in glove or shoe size.
PHYSICAL EXAM
 General: appears weak, awake, apathetic, not
so responsive, anasarca
Vital Signs: T= 36.5 C
W= 33kg
BP = 100/70 mmHg
HR = 110 bpm
Skin: (+) dry and scaly rash in the abdomen
and inguinal area
(+) edematous, mostly non-pitting
 HEENT:
Head: (-) injury
(-) lesion
(+) puffy face
Eyes: (-) pale conjuctivae
(+) conjunctival edema
anicteric sclera
Ears: (-) discharge
Nose: (-) discharge
Throat: (-) discharge
Neck: (-) lymphadenopathy
 Thorax and lungs: (-) wheezing
(-) crackles

Cardiovascular: (-) murmurs

Abdomen: (+) protuberant

(+) dry and scaly rashes
(+) tenderness

Genitalia: (+) edematous penile shaft

(+) rashes on inguinal area
DIFFERENTIALS
Acute glomerulonephritis
kwashiorkor
Neprotic Syndrome
ACUTE GLOMERULONEPHRITIS
ACUTE GLOMERULONEPHRITIS
ACUTE GLOMERULONEPHRITIS
ACUTE GLOMERULONEPHRITIS
 ACUTE GLOMERULONEPHRITIS

Management:
Bed rest and limitation of physical activity
Na restriction to 2g/day
Fuid restriction 400-600ml/day
Loop diuretics
Urinary output 24hr
Antibiotic therapy
 ACUTE GLOMERULONEPHRITIS

Rule- out:
Hematuria not present
BP 100/70
Specific gravity normal
KWASHIORKOR
KWASHIORKOR
KWASHIORKOR
KWASHIORKOR
KWASHIORKOR
NEPHROTIC SYNDROME
NEPHROTIC SYNDROME
NEPHROTIC SYNDROME
NEPHROTIC SYNDROME
PARACLINICALS OBTAIN FROM
THE PATIENT
Urinalysis:
Specific gravity: 1.030
pH: 6.5
protein: +
blood : (-)
leukocyte: (-)
nitrite: (-)
WBC: 0-5/hpf
RBC: 0-7/hpf
 Blood chemistry: CBC:
Creatinine: 0.4 WBC: 11 x 103/uL
mg/dL Neutrophil: 70%
BUN: 8 mg/dL Lymphocyte: 30%
Platelet: 350 x
103/uL
Haemoglobin: 9.0
g/dL
Hct: 30%
 CXR: opacity noted on both lung fields,
obliterating the costophrenic angle
 Additional lab tests needed:
1) Serum albumin to determine the extent of
hypoalbuminemia
2) Peripheral blood smear to confirm iron
deficiency anemia
3) serum lipids usually high for nephrotic
syndrome
Final diagnosis:

PRIMARY OR IDIOPATHIC
NEPHROTIC SYNDROME
Definition
a manifestation of glomerular disease
characterized by nephrotic range
proteinuria and the triad of clinical fi
ndings associated with large urinary
losses of protein: 1. hypoalbuminemia, 2.
edema, and 3. Hyperlipidemia

Nephrotic range proteinuria is defi ned as

protein excretion of > 40 mg/m 2 /hr or
a first morning protein : creatinine ratio
of > 2-3 : 1
TREATMENT
 prednisone
at a dose of 60 mg/m 2 /day (maximum daily dose, 80 mg)
in a single daily dose for 4-6 consecutive wk.
After the initial 6-wk course
tapered to 40 mg/m 2 /day given every other day as a single
daily dose for at least 4 wk - 2 months
severe symptomatic edema - sodium restriction
(a low-sodium diet) and fluid restriction
swollen scrotum - pillows to enhance fluid
removal by gravity
administration of loop diuretics (furosemide),
orally or intravenously
 significant generalized edema
IV administration of 25% albumin (0.5-1.0 g
albumin/kg), as a slow infusion followed by furosemide
(1-2 mg/kg/dose IV)
collaboration with a pediatric nephrologist
close monitoring of volume status, blood pressure,
serum electrolyte balance, and renal function.
Symptomatic volume overload, with
hypertension, heart failure, and
pulmonary edema is a potential
complication of parenteral albumin
therapy, particularly when administered
as rapid infusions.
 successful education of the family
regarding all aspects of the condition
pathophysiology and treatment of nephrotic syndrome
must be carefully reviewed with the family
The child s parents must be able to recognize the
signs and symptoms of the complications
 relapse
infrequent relapsers - 3 or less per year
Frequent relapsers - 4 or more per year
steroid therapy
steroid dependant - relapse following dose
reduction or discontinuation
steroid resistant - partial or no response to
initial treatment
Children who continue to have proteinuria (2 + or greater)
after 8 wk of steroid therapy are considered steroid
resistant, and a diagnostic renal biopsy should be
performed.
RELAPSES TREATMENT

prednisone dose of 60 mg/m 2 /day (80

mg daily max) in a single am dose until
the child enters remission (urine trace or
negative for protein for 3 consecutive
days).
then changed to alternate-day dosing as
noted with initial therapy, and gradually
tapered over 4-8 wk.
FREQUENTLY RELAPSING AND
STEROID-DEPENDENT TREATMENT
Cyclophosphamide
prolongs the duration of remission and reduces the
number of relapses
side effects of the drug (neutropenia, disseminated
varicella, hemorrhagic cystitis, alopecia, sterility,
increased risk of future malignancy)
Cyclophosphamide (2 mg/kg) is given as a single oral
dose for a total duration of 8-12 wk
Alternate-day prednisone therapy is often continued
withheld if the WBC count falls below 5,000/mm 3
FREQUENTLY RELAPSING AND
STEROID-DEPENDENT TREATMENT
Cyclosporine or tacrolimus
Mycophenolate
Levamisole - an anthelmintic agent with
immunomodulating effects
Most children who respond to cyclosporine,
tacrolimus, or mycophenolate therapy tend to
relapse when the medication is discontinued.
Angiotensin-converting enzyme (ACE) inhibitors
and angiotensin II blockers may be helpful as
adjunct therapy to reduce proteinuria
COMPLICATIONS
Infection (major)

Spontaneous bacterial peritonitis is a common infection
sepsis,
pneumonia,
cellulitis, and
urinary tract infection
seek medical attention if the child appears ill,
has a fever, or complains of persistent
abdominal pain.
COMPLICATIONS
increased risk of thromboembolic events
related to increased prothrombotic factors (fi brinogen,
thrombocytosis, hemoconcentration, relative immobilization)
and decreased fi brinolytic factors (urinary losses of
antithrombin III, proteins C and S)
Hyperlipidemia can cause cardiovascular disease
Steroid toxicity
Edema
Acute renal failure
PROGNOSIS
Steroid responsive nephrotic syndrome : good
prognosis (MCNS)
Steroid resistant nephrotic syndrome: poor
prognosis (FSGS)