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CASE 3

CASE 3. نرگس حجازی 5ساله با شرح حال تشنج فوکال که از 7روز قبل فنوباربیتال مصرف کرده است. Cc: تب از 2روز قبل و راش ماکولو پاپولر اریتماتوز T=39. LAB: WBC:7.1 3.7 HB: 11.9 12.2 PLT: 159 132 100 EOS: 3% 1% ESR: 15 35 CRP:3+ UC(-) BC(-)

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CASE 3

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  1. CASE 3

  2. نرگس حجازی 5ساله با شرح حال تشنج فوکال که از 7روز قبل فنوباربیتال مصرف کرده است. Cc:تب از 2روز قبل و راش ماکولو پاپولر اریتماتوز T=39

  3. LAB: WBC:7.1 3.7 HB: 11.9 12.2 PLT: 159 132 100 EOS: 3% 1% ESR: 15 35 CRP:3+ UC(-) BC(-) AST: 444 72 ALT: 394 227 ALP: 461

  4. PLAN قطع فنوباربیتال و شروع کلونازپام قطع تب پس از 4روز بهبود راشها پس از 2روز

  5. DX • DRESS S.

  6. FOLLOW UP عدم ادامه تب WBC:6.9 HB:12.8 PLT:376 EOS:3.4 ESR”23 CRP:NEG ALT:14 AST:45 ALP:374

  7. Case 4 • 5 month girl • Cc:FTT • History of 2 hospitalization for pneuminia and FTT • Bw:2700 • Nw:4.5

  8. LAB: Wbc 16.4 ph:7.5 Hb:9 co2:29 Plt:318 Hco3:24.6 Ur:10 SE:NL Cr:0.3 AST:102 ALT54 ALP590 Na:134 K:3.4

  9. CXR: infiltration Other lab NL PLAN: Ab therapy Sweat test: cl=65 na=55

  10. DX • CYSTIC FIBROSIS • PLAN:SWEAT TEST

  11. In the name of GOD

  12. CASE 1

  13. ID: AmirHosseinRahmani CC: Weakness PI: A 10yrs old male presented with nausea and headache from 1 days ago followed by walking disability and weakness. He had a history of paresthesia in distal parts of the limbs from 1 month later.

  14. PMH Without a significant abnormality

  15. Physical Examination Normal vital sign Normal general examination Normal cranial nerves Normal sensory system Normal DTR Force of lower limbs Flexor plantar reflex

  16. Laboratory Data BS: 141 Urea: 36 Cr: 0.7 Na: 137 K: 4.5 Ca: 10.1 WBC: 11700 Neut: 80/ Lym: 12 RBC: 4.4 Hb: 12.6 Hct: 36.4 Plt: 323000 CPK: 248

  17. EEG • Showed sharp waves at occipitotemboral lobe • Brain CT Scan: • Normal

  18. Psychiatric consult: Conversion Disorder

  19. Final diagnosis Conversion disorder

  20. CASE: 2

  21. ID: SalehehGolmakani CC: Weakness and gait disorder PI: A 8 yrs old female presented with flue- like syndrome from 4 days ago followed by low back pain and walking disability.

  22. PMH No significant abnormality

  23. Physical Examination Normal vital sign Normal general examination Normal cranial nerves Sensory level at thoracolumbar area Decrease muscular force at lower limbs DTR of lower limbs Plantar reflex: Babinski

  24. Laboratory Data • BS: 81 • Urea: 40 • Cr: 0.5 • K: 4.2 • Ca: 10.1 • Mg: 2.3 • U/A: Nl • RBC: 4.5/ Hb:13.5/ Hct: 39.4/ MCV: 85.8 • WBC: 7700 (neut: 72, lym: 20) • CSF: • sugar: 79/ pr: 19/ LDH: 26/ chol: 0 • WBC: 47 (neut:80, lym: 20)/ RBC: 0

  25. others Anti- HIV: neg Anti- HTLV1: neg Anti ds DNA: 21 C3: 175 C4: 35 ANA: 9 RF: neg B/C: neg U/C: neg CSF/C: neg

  26. SSEPS: • Nl • MRI: • hyperintensity of right temporoparietal lobe and medula at T2

  27. Final diagnosis Demyelinating disorder probably MS

  28. Case Report

  29. CASE 1 An 6 m old infant came with CC of FTT + Cough

  30. Lab Results • VBG: Ph =7.30 • PCO2 = 13.7 • HCO3 = 7.7 • Urea : 19 _ Cr : 0.5 • U/A : Ph = 6 • U/C : Neg • B/C : Neg

  31. Radiology • Plenty of stones with the size of 0.5 _ 1.5mm in calises in both kidneys and nephrocalcinosis

  32. Diagnosis • Renal Tubular Acidosis type I (RTA I)

  33. Diagnosis • Type I RTA is presented with normal AG(hyperchloremic metabolic acidosis) metabolic compensation for respiratory alkalosis produces an electrolyte pattern that is identical to that seen in a normal AG acidosis thus the first step in the diagnosis of the patient with the reduced serum bicarbonate and elevated chloride concentration is to confirm that metabolic acidosis is present by measuring the blood Ph

  34. Urine Ph • Patient with normal renal function and normal renal acidification mechanism would develop metabolic acidosis usually have a urine Ph of 5.3 or less as ammonia (NH3) defuses into the tubular lumen it mostly combines with hydrogen ions to form ammonium (NH4+) the reduction in the free hydrogen ion concentration elevates the urine Ph depending upon the chronicity of the acidosis and the degree of hypokalemia the urine Ph may be 5.5 or higher .

  35. In most cases of distal RTA the urine Ph is persistently 5.5 or higher

  36. Treatment • The correction of the metabolic acidosis results is restoration of normal growth rates in children and also has the following benefits: • Minimizing new stone formation and nephrocalcinosis . • Demolishing calcium losses induced by bone buffering of some of the return acid .

  37. The aim of alkali therapy is to achieve a relatively normal serum bicarbonate concentration (22 to 24 meq/lit) • Children may require as much as 4_8 meq/kg/day in divided doses because they often have a higher fix urine Ph as a result fixed bicarbonate losses are frequently higher than in adults . • Potassium citrate alone or with sodium citrate (polycitrate) is indicated in patient with persistent hypokalemia or calcium stone disease but not in patients with the hyperKalemic form of distal RTA

  38. CASE 2 • A 3.5 year old boy with the history of 2 times complex seizure in the last month and under the treatment with Phenobarbital which happened to appear with fever , rash and conjuctivitis and didn’t respond to antibiotic therapy

  39. Lab Results • WBC=4.1 3.9 3.4 9.5 3.8 • Hb = 9.1 10.5 9.1 9.2 8.1 • Plt = 128 191 434 690 544 • ESR = 12 70 101 • CRP = 3+ 2+ 3+

  40. U/A : NL • U/C : Neg • B/C : Neg • AST = 131 41 • ALT = 134 65 • ALP = 649 • Echocardiography : NL

  41. Diagnostic criterias of Kawasaki disease

  42. Laboratory criterias

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