6b. Renal Disease - Paediatric Case Study
The course content the following article will help you complete the case study (Reading Renal 5).
Jacqui, aged 5 years, presented to her general practitioner with moderate generalised pain in her abdominal region, a high temperature (41°C) and chills, frequent and painful urination, proteinuria and haematuria. Her general practitioner advised Jacqui’s parents to take Jacqui to Emergency Department at their local hospital because she might need intravenous antibiotics, and then phoned to advise the senior medical officer in advance of their arrival. On presentation at the Emergency Department, Jacqui’s pain had worsened, her blood pressure was 120/80 mmHg and pulse 120 beats per minute.
Reducing her pain was the initial priority and Jacqui was prescribed intravenous morphine and oral paracetamol. Further questioning of her parents revealed that Jacqui had previously had a urinary tract infection, had been 'difficult to toilet train', still wets her bed reasonably frequently and occasionally has some daytime urine leakage particularly if she cannot go to the toilet regularly.
After her pain subsided further tests were arranged. An investigative ultrasound examination revealed minor renal swelling and ureteral dilatation. Jacqui was admitted to hospital and commenced on intravenous gentamicin. Jacqui was encouraged to drink plenty of water and her fluid intake and urine output were monitored.
Jacqui’s blood and urine test results are outlined below (with age-specific reference range):
Biological variable Patient results Normal range
White blood cell count 15 x 109/L 4.5 – 12 x 109/L
Haemoglobin 120 g/L 113 –145 g/L
Haematocrit
0.45 % 0.33 – 0.42 %
Mean cell volume 75 fL 74 – 87 fL
Sodium 145 mmol/L 135 –145 mmol/L
Potassium 5.2 mmol/L 3.5 – 5.3 mmol/L
Serum creatinine 118 µmol/L 25 – 70 µmol/L
Microalbuminuria 45 mg/L 30 mg/L
Urinary albumin: creatinine ratio (ACR) 40 mg/mmol 30 mg/mmol
Estimated glomerular filtration rate (eGFR) 80 ml/min/1.73m2 eGFR 90 ml/min/1.73m2
Microscopy urinary analysis revealed haematuria. A midstream urine culture indicated high levels of Escherichia coli (E. Coli), which is the most common cause of urinary tract infection,33 and sensitivity to gentamicin.
Following test and examination results, Jacqui was diagnosed with an acute pyelonephritis and urinary tract infection, secondary to a urinary tract anomaly. This is most commonly due to an ectopic ureter or abnormal insertion of the ureter into the bladder, which is associated with vesicoureteral reflux.34
Jacqui was discharged after three days, with a normal glomerular filtration rate, greatly reduced proteinuria and haematuria and mild residual pain, indicating effective antibiotic treatment.35 36 Augmentin (oral amoxicillin and clavulanate)37 was prescribed for ten days, and paracetamol as required. Jacqui was referred to the urology team for follow-up x-ray imaging to check for retrograde urine flow or a structural abnormality that could explain her history of urinary problems and recent pyelonephritis.
1. Describe the virulent factors of E. Coli that have resulted in Jacqui developing pyelonephritis.
2. Explain how pyelonephritis leads to albuminuria and haematuria.
3. Discuss the reasons why Jacqui was treated with intravenous gentamicin and encouraged to drink water.
7
7. Type 1 Diabetes Case Study
Moana is a slim 19-year-old Maori woman who presented to the emergency department with an upper respiratory tract infection, fatigue and nausea. On further questioning, she complained of having a sore throat earlier in the month and a two-week history of polyuria and polydipsia. She also mentioned that her usually tight-fitting jeans were quite loose.
On presentation her heart rate was 100 beats per minute, blood pressure was 105/65 mmHg, respirations 25 breaths per minute and temperature 37.5oC. Based on her presentation and blood test results outlined below, a tentative diagnosis of type 1 diabetes was made, and will be confirmed if she tests positive for islet cell antibodies.
Her grandfather had type 2 diabetes, but no other close relatives have diabetes. Moana often has a cigarette when she is out socially. She is not currently on any medication and works and studies part-time in the hospitality industry. She lives with her parents and three siblings, is usually quite active and plays competitive netball.
Moana’s blood test results on presentation.
Biological variable Patient results Normal range
Capillary glucose 27 mmol/L 7.0 mmol/L
HbA1c 66 mmol/mol 41 mmol/mol
PaCO2 23.0 mmHg 35 – 45 mmHg
Oxygen saturation 99% 95 – 100%
pH 7.32 7.35 – 7.45
Actual bicarbonate 24 mmol/L 23 – 28 mmol/L
Potassium (K+) 5.5 mmol/L 3.5 – 5.3 mmol/L
Sodium (Na+) 145 mg/mmol 135 –140 mg/mmol
Serum creatinine 92 umol/L 45 – 90 umol/L
Urea 5.7 mmol/L 3.6 – 5.0 mmol/L
Serum ketones 5.4 mmol/L 0.1 mmol/L
Haemoglobin (Hb) 140 g/L 115 – 155 g/L
White blood cell count 9 x 109/L 4 – 11 x 109/L
Mean cell volume (MCV) 105 fL 80 – 99 fL
1. Proteins on bacteria and viruses are called antigens.38 Explain why major histocompatibility complexes (MHC) on beta cells are referred to as antigens in people diagnosed with type 1 diabetes. (Include discussion of the immune system in your answer.)
2. Moana has classic signs and symptoms of diabetic ketoacidosis (DKA). Explain the hormonal and metabolic changes that result in ketoacidosis.
3. Following diagnosis and recovery from DKA, it is most important for Moana to achieve normoglycemia (through exogenous insulin, appropriate nutrition and physical activity), and not smoke to prevent microvascular complications (retinopathy and nephropathy).39 Discuss the rationale for focusing management on glycaemic control rather than cardiovascular risk factors.
8
9. Asthma Case Study
Maria is aged 24 years and immigrated to New Zealand from Serbia when she was 14 years old. She reported having mild asthma symptoms when she was young, but never required medical attention for these symptoms. Since arriving in New Zealand, she has experienced several episodes of mild asthma-like symptoms (shortness of breath, episodes of coughing during the night and an expiratory wheeze), which progressively worsened over time.
After one acute episode at 17 years, Maria was diagnosed with asthma by her general practitioner and prescribed Flixotide (fluticasone; 2 puffs twice per day), and Ventolin (salbutamol) as required. She regularly woke at night with difficulty breathing in her mid-to-late teens and had to give up playing netball because her asthma and fatigue made it hard for her to train. Maria completed a degree in arts and design and now works as a graphic designer. She is 170 cm tall and weighs 74 kg.
Maria has been brought to the local Emergency Department by her friends, during a severe asthma attack which started while attending a friend’s flat-warming party in a house with cats. Although Maria used her friend’s Ventolin inhaler, her symptoms did not appear to improve, and a recent winter cold appeared to exacerbate the symptoms. Upon arrival at the Emergency Department she was very distressed, unable to speak using full sentences, was short of breath with a sensation of chest tightness and exhibited both expiratory and inspiratory wheezing. Her oxygen saturation (SpO2) was 88%, heart rate 130 per minute, respirations 32 per minute and she was using her accessory respiratory muscles to breathe. Her peak expiratory flow (PEF) was 200 L per minute (45% of predicted value; 449 L per minute) and auscultation revealed a loud expiratory wheeze. She admitted to the consulting doctor that she often forgets to take her Flixotide medication.
Maria was given Ventolin via a spacer, six puffs every 20 minutes and 40 mg of oral prednisone as recommended.45 As this did not provide immediate relief, she was also given six puffs of ipratropium bromide. After 60 minutes her peak flow improved to 310 L per minute, respirations 25 per minute, heart rate 90 beats per minute, SpO2 94% and her use of accessory muscles and expiratory wheeze were reduced.
Maria’s current symptoms continued to improve, and her peak flow was 360 L per minute after 2 hours. Maria was discharged in the early hours of the morning into the care of her parents. She was prescribed 40 mg oral prednisone for 5 days, in addition to Seretide (fluticasone propionate 50 mcg/salmeterol 25 mcg) 2 puffs per day and Ventolin as required. Maria was reminded to ensure she has up-to-date inhalers and to be vigilant in taking Seretide in the morning and evening to reduce the risk of further acute episodes of asthma.
1. Tumour necrosis factor (TNF)-alpha is thought to have a wide range of pro-inflammatory effects in the pathophysiology of asthma.46 Explain how TNF-alpha acts to exacerbate Maria’s asthma allergic response.
2. Some individuals with asthma develop irreversible structural changes to airways known as remodelling.47 48 Describe these chronic changes and explain how they are likely to affect Maria’s symptoms.
3. Breathing exercises, such as Papworth, Buteyko, and yoga methods, are commonly used as nonpharmacological strategies for managing symptoms and the impact of asthma on daily life.49 50 51 Explain the main aims of such breathing exercises and how these are thought to reduce breathing-related symptoms.
10
10a. COPD Adult Case Study (Complete 10a OR 10b)
Answer the questions relating to Mrs Brooks (adult) OR Marta (paediatric) case study.
Mrs Brooks, aged 70 years of Maori ethnicity, is a retired office manager from Wellington, who lives alone after her husband passed away last year. She was diagnosed with chronic bronchitis, a chronic obstructive pulmonary disease (COPD), 10 years ago and has experienced several exacerbations since, including a prolonged one during the previous winter. She has smoked for most of her adult life, and although she has not been able to stop for any length of time, she has greatly reduced her cigarette use to about five per day.
Mrs Brooks is currently consulting with her general practitioner (GP) while experiencing another exacerbation following an upper respiratory viral infection. She complains of gasping for breath during light exertion such as when quickly standing and walking to answer the telephone. She has regular bouts of productive coughing, including prolonged episodes over the previous three winters, and on some days had found it difficult to dress and stay up for the day. On examination, Mrs Brooks had a pronounced wheeze and fits of coughing with clear sputum. She also has moderate to severe peripheral oedema in her lower legs, ankles and feet, and a slight cyanosis, particularly in her face and nose.
Mrs Brooke’s BMI is 34 kg/m2, blood pressure 140/85mmHg, temperature 36.1 and FEV1/FVC was 66%. Mrs Brooks regular medications include captopril, atorvastatin, aspirin and a Serevent inhaler. After the examination and due to her low eosinophil count, she was prescribed Seretide instead of Serevent,52 and referred her to a new community smoking cessation programme. Her GP will telephone her over the next few days to check of her progress and arrange further follow up if required.
Mrs Brook’s blood and respiratory recent test results.
Biological variable Patient results Normal values (mean±SD)
HbA1c 38 mmol/mol, 42 mmol/mol
Haemoglobin 160 g/L 115 – 155 g/L
Haematocrit 0.48 L/L 0.34 – 0.46 L/L
Mean cell volume 85 fL 80 – 99 fL
C-reactive protein 29 mg/L 0 – 5mg/L
White blood cell count 16 x 109/L 4.0 – 11.0 x 109/L
Neutrophils 4.5 x 109/L 1.9 – 7.5 x 109/L
Eosinophils 0.08 x 109/L 0.0 – 0.5 x 109/L
Forced Vital Capacity (FVC) 2.80 L (2.5 ± 0.4 L)
Peak Expiratory Flow (PEF) 5.50 L/s (5.8 ± 0.9 L/s)
Forced Expired Volume in 1 s (FEV1) 1.85 L (2.1 ± 0.3 L)
Total cholesterol 5.2 mmol/L 5.0 mmol/L
Low-density lipoprotein cholesterol (LDL-C) 3.5 mmol/L 3.4mmol/L
High-density lipoprotein cholesterol (HDL-C) 1.2 mmol/L 1.0 mmol/L
Triglycerides (TAGs) 1.3 mmol/L 1.7 mmol/L
Total cholesterol:HDL ratio 4.3 mmol/L 4.5 mmol/L
Serum creatinine 50 µmol/L 25 – 70 µmol/L
1. Explain how nicotine and other toxins from cigarette smoke contribute to the pathological changes associated with chronic bronchitis.
2. Mrs Brooks presents with moderate to severe peripheral oedema, which is associated with chronic bronchitis.52 Explain how chronic bronchitis can cause lower limb oedema.
3. Referring to GOLD guidelines,52 explain the likely reason why her GP has changed her medication from Serevent (salmeterol xinafoate) to Seretide (salmeterol xinafoate/fluticasone propionate).
11