Clinico-Pathologic Conference
Clinico-Pathologic Conference 2015Post-Graduate InternsOspital
ng Maynila Medical Center
{JA12-year old MaleCatholic
Loss of consciousnessChief ComplaintSwelling of ankles, knees,
and elbow joints including phalangeal jointsintermittent
undocumented low grade feverParacetamol givenCondition progressed
until there was difficulty in ambulation.4 months PTACondition
persistedDiagnosis not known to the parentsPatient discharged
improvedHome meds: Penicillin, Prednisone, AlMgOH3 months PTAJoint
pains recurredIbuprofen: no relief2 months PTAPE: swollen knees,
ankles, and phalangeal joints, bilateralVital signs were within
normal. Initial impression: Juvenile Rheumatoid ArthritisMeds:
Aspirin
Upon admissionCBCHemoglobin 107WBC count 9.1 (Neutrophils
64%)Platelet count 924
ESR 78 mm/hrASO Positive up to 1:4 dilutionC3 1840 mg/L
CXR NormalX-ray of bilateral knees and ankles: no bone
involvementUpon admissionRheumatology service: Impression:
JRASGPT/SGOT, urinalysis, Anti Nuclear Antibody: normal Rheumatoid
Factor: not done (financial constraints)Penicillin discontinued,
Aspirin was continued
Still with occasional joint pains and difficulty in
ambulation3rd hospital dayJoint pains resolved Good motor activity
Aspirin decreased8th hospital dayDischarged improvedFollow up at
Rheumatology OPD clinic and Rehabilitation Medicine
11th hospital dayRheumatology OPDRheumatoid Factor: negative
Aspirin continued Prednisone started
However, patient was lost to follow-up.
Joint pains recurredPolymigratory Afebrile
2 weeks PTAJoint pains recurredFebrile (38.5C)
Medications were continued until
1 day PTA1 episode of post-prandial vomiting DysphagiaLoss of
consciousness
Re-admitted
Few hours PTA(+) anorexia(-) rashes (-) diarrhea (-) easy
fatigability(-) headache(-) pallor(-) blurring of vision(-)
melena(-) bleeding tendenciesReview of Systems(-) ear/nasal
discharge(-) constipation(-) seizure(-) cough(-) dysuria(-)
frequency(-) dyspnea(-) weight loss
PAST MEDICAL HISTORY:FAMILY MEDICAL HISTORY:BIRTH AND MATERNAL
HISTORY:Born to a 30 y/o G3P2(2012) mother via NSD at a Lying-In
clinic No feto-maternal complications notedMother had irregular
pre-natal check-ups at the local health center, with irregular
intake of multivitamins and ferrous sulfate. (-) Maternal
illness
FEEDING HISTORY:Px was breastfed up to 1 year of age then
shifted to milk formula (Bear Brand)Px was feeding on adult diet
prior to illnessIMMUNIZATION HISTORY:(+) BCG(+) DPT3OPV3(+)
measles(-) Hepatitis BDEVELOPMENTAL HISTORY:At par with age
Asleep, not in cardio-respiratory distressHR: 90/minRR:
30/minBP: 140/100 (>p90)Temp: 37.5Wt: 17.9 kg (p5)Ht:110 cm
(p10) Weight for age: 85%Height for age: 94% (mild stunting) Weight
for actual height: 94% (no wasting)PHYSICAL EXAMINATIONAnicteric
sclerae, slightly pale conjunctivae, (-) naso-aural discharge, (-)
tonsillo-pharyngeal congestionEqual chest expansion, clear breath
sounds, (-) retractions, (-) crackles, (-) wheezesAdynamic
precordium, distinct heart sounds, normal rate, regular rhythm, (-)
murmurGlobular, soft abdomen, normoactive bowel sounds, non-tender,
no palpable massFull and equal pulses, (-) edema, (+) limitation of
range of motion both kneesand ankles, (+) tenderness
metatarsophalangeal joints, knees, ankles, wrists, proximal
carpo-phalangeal joints, (-) erythema
PHYSICAL EXAMINATIONConscious, coherentPupils 2 mm EBRTLFull
EOMs(+) corneals(-) facial asymmetryintact gross hearingcan shrug
shoulderstongue midlineMeningeals: supple neckSensory: withdraws to
pain on all extremitiesMotor: 5/5 : 5/5________________3-4/5 :
3-4/5Reflexes: ++Cerebellar: (-) nystagmus; can do finger to nose
test
Neurologic ExaminationImpression: Malignant Hypertension
secondary to steroid intake
Prednisone at 1.6 mg/kg/dayAspirin at 54 mg/kg/dayAlMgOH
Furosemide 1 mg/kg/dose given once a day Nifedipine 5mg/cap SL, prn
for BP > 135/85
Referred back to Rheumatology service.
Upon admissionRheumatology service agreed with diagnosis.
Aspirin Gradual tapering of Prednisone up to a dose of
0.25mg/kg/dayAfebrile No hypertensive episodes or joint pains
Upon admission2nd HDFacial edema Adequate urine outputUpon
admission2nd HD3rd-4th HDOn and off joint painsEpisodes of
hypertensionFacial edema persisted
Nifedipine prn continuedUpon admission2nd HD3rd-4th HD5th
HDSevere joint pains (Nalbuphine given)Facial edema persistedRepeat
urinalysis, BUN, creatinine : Normal resultsUrine output
adequateUpon admission2nd HD3rd-4th HD5th HD6th7th HDNo episodes of
hypertensionTapering of Prednisone was continuedUpon admission2nd
HD3rd-4th HD5th HD6th7th HD8th HDFacial edema resolved Adequate
urine outputFurosemide discontinuedEpisodes of severe joint
painsUpon admission2nd HD3rd-4th HD5th HD6th7th HD8th HD9th HDMore
paleAbdomen slightly enlarged Palpable masses on both flanksRepeat
CBC: hgb of 56pRBC transfusion Post BT hgb: 108
Upon admission2nd HD3rd-4th HD5th HD6th7th HD8th HD9th HD11th
HDAbdominal UTZ: Enlarged kidneys with bilateral renal parenchymal
disease
Oncology service: Lymphoma R/O Pheochromocytoma
Suggest: abdominal CT Scan, urinary VMA determination (not done
due to lack of funds), and possible renal biopsyUpon admission2nd
HD3rd-4th HD5th HD6th7th HD8th HD9th HD11th HD15th HDNephrology
service Urinalysis and BUN/creatinine: normalUpon admission2nd
HD3rd-4th HD5th HD6th7th HD8th HD9th HD11th HD15th HD19th
HDNephrology service: intra-abdominal mass
Urine culture and UTZ of the adrenals (not done due to financial
constraints)
Prednisone and Aspirin discontinued
Gradual, progressive abdominal enlargementEpisodes of severe
joint pains persistedUpon admission2nd HD3rd-4th HD5th HD6th7th
HD8th HD9th HD11th HD15th HD19th HD21st HDAbdominal CT scan:
Hepatomegaly with prominent spleen, enlarged kidneys with
obstructive hydronephrosis, and retroperitoneal lymphadenopathy.
Overall findings were consistent with a neoplastic process. Upon
admission2nd HD3rd-4th HD5th HD6th7th HD8th HD9th HD11th HD15th
HD19th HD21st HD28th HD(+) pallor Repeat CBC: Hgb of 42pRBC
transfusion given30th HDNephrology service: suggest open renal
biopsy Referred to Urology service
Oncology service: requested for tumor markers and serum LDH: 800
(2x elevated)
Biopsy of the retroperitoneal lymph nodes30th HD36th HDHgb
48pRBC transfusion(+) severe joint pains (Tramadol)Abdominal
enlargement persisted30th HD36th HD38th HDHgb of 64Platelet count
14Platelet concentrate transfusionDifficulty of breathing with
distended abdomenHigh back rest and oxygen inhalation at 2 Lpm30th
HD36th HD38th HD41st HDBMAhypocellular marrow, no megakaryocytes,
with few myeloid series seen, with no signs of maturational arrest,
and most of the cells were mature lymphocytes
Again started on Prednisone at 1 mg/kg/day30th HD36th HD38th
HD41st HD47th HD(+) abdominal painRanitidine started30th HD36th
HD38th HD41st HD47th HD48th HD(+) Difficulty of breathing
progressing to gasping respirationPatient intubated -> cardiac
arrest49th HD
