Case Presentation

Department of Pathology
(March 24 – 31, 2018)

Alinsugay, Amytess
Landero, Jaime Vinc Angelo
Singco, Shera Efraim
Yrauda, Noreen Joyce
General Data
• M.A., 14 year old female, child, from Basak, Mandaue, Cebu, born on
February 23, 2003, was admitted for the first time at VSMMC last
January 16, 2018 due to fever
Prenatal History
• Maternal age 20 years old

• Obstetric Score upon pregnancy G1P0

• First prenatal check up 12 weeks AOG

• Medications: Ferrous Sulfate

• No maternal illnesses
Natal History
• Birth rank 1/1

• Born live term, female neonate delivered via NSD with good cry, BW 3,600gm
with good cry at VSMMC

• No cord coil, no jaundice, no cyanosis

• Complete immunisations as claimed including one dose of Dengvaxia last June

2017

• Breastfed from birth up to two weeks, then on mixed feeding

• Weaned at 6 months with soft foods

Past Medical History
• Admitted at VCMC, Eversley and VSMMC last 2017 due to fever, boys
malaise and headache
• No previous illnesses
• No allergies to food or drugs
Family History
• Hypertension
• Cardiac disease
• Bronchial Asthma
Personal History
• Eldest child
• Grade 9 student in local high school
• Primary caregiver is mother
History of Present Illness
October 1, 2017

• Bipedal edema associated with lower extremity rashes

sought consult at UC Med, managed as a case of
cellulitis, given Cefalexin and Ibuprofen. CBC taken was
unremarkable and Urinalysis revealed trace proteinuria
and hematuria.
History of Present Illness
December 12, 2017

• Noted fever Tmax 39C, body malaise, headache,

and had multiple admissions from VCMC, Eversley
Hospital and VSMMC. Dengue Combo test only
revealed (+) IgG . CBC taken were unremarkable.
Patient was then discharged with unrecalled
diagnosis
History of Present Illness
January 16, 2017
• Three days prior to admission, patient had onset of remitting fever
with Tmax 38.2C, no medications given, associated with headache,
body malaise and abdominal pain. Persistence prompted consult thus
subsequent admission
Physical Examination
• General Survey: awake, conscious, coherent
• Vital Signs:
• BP: 110/80 mmHg
• HR: 91 bpm
• RR: 21 cpm
• T: 37C
• Wt: 47 kg
Physical Examination
Skin: Warm with good turgor and mobility, no lesions, no bruises

HEENT: Pink palpebral conjunctivae, anicteric sclera

Neck: no cervical lymphadenopathy

Chest and Lungs: Equal chest expansion, clear breath sounds

CVS: Adynamic precordium, no murmurs, PMI at 5th ICS MCL

GUT: Negative KPS bilaterally, grossly female

Physical Examination
Abdomen: Flat, normoactive bowel sounds, tympanitic, non-
tender

Extremities: Strong peripheral pulses, no edema, warm to touch

Motor: 5/5 on both upper and lower extremities

CNS: No gross neurologic deficits with intact cranial nerves

Course in the Wards
Hospital Week 1 (Jan. 16-22,2018)
S O A P
(+) hx of fever, nausea, General: awake, • Dengue Fever with • IVF: PNSS 1L
abdominal pain, body conscious, coherent Warning Signs @35gtts/min (3cc/kg)
malaise, headache Vital Signs • Labs:
BP: 110/70 • Dengue NS1, IgG,
(+) subsequent lysis of HR: 97 IgM, CBC, Hct,
fever RR: 23 • Paracetamol
(+) persistent abdominal T: 38C 500mg/tab 1tab q6H
pain PRN for temp >38C
(+) adequate UO - (+) abdominal
tenderness • Additional Labs:
- warm ext; CRT <2secs; • C3, Albumin,
strong peripheral Cholesterol, S.
pulses crea, BUN, ASO
Hospital Week 2 (Jan. 23-29,2018)
S O A P
(+) febrile episodes Vital Signs • T/C Henoch-Schonlein • For repeat CBC, PT,
(+) gingival bleeding, BP: 110/70 Purpura APTT
active up to 40cc in total HR: 90’s • HSP Nephritis vs. • To secure 1 unit of
RR: 24 Lupus Nephritis PRBC
T: 38C – 39.3C • Furosemide 40mg
IVTT then adjusted to
UO: 0.88 cc/hr 4.2 cc/hr
Hospital Week 3 (Jan. 30 – Feb.5, 2018)
S O A P
Feb1: (+) 200ml vomiting Vital Signs • T/C Systemic Lupus • IVF: PLR 1L
BP: 110/70 Erythematosus @18gtts/min (1.5
HR: 90’s • Hospital Acquired cc/kg)
RR: 20 Infection • For S. electrolytes
T: 37.5 – 38.5

Feb2: (+) oral sores • For ANA consult with

Pedia Rheuma
• For UPCR
• Start:
• Piperacillin +
Tazobactam
• Amikacin
• K-lyte tab TID x
2days
Hospital Week 3 (Jan. 30 – Feb.5, 2018)
S O A P
Feb3 – Feb4: (+) oral UO noted: • T/C Rapidly Progressive • Appraised for possible
ulcers; (+) 11pm: 0.2cc/kg/hr Glomerulonephritis hemodialysis
thrombocytopenia; (+) 12am: 0.4cc/kg/hr • MR mild, TR mild, • Increase
discoid rashes; (+) 1am: 0.1cc/kg/hr prob. sec. to SLE hydrocortisone
carditis; (+) mouth sores; GFR: 28.2 ml/min/1.73m2 carditis • Trans-in to PICU
(+) joint pains (+) wheeze on both lungs • For 2D Echo
• For ABG, ANA,
Coomb’s Test
Feb 3
Urine creatinine (random) 271.8 mg/dl
Total urine protein 440 mg/dl(H)

Feb 3: Antinuclear Antibody Testing (Indirect Immunoflourescence Test)

Substrate Hep-2 Cells
Result (+) Positive
Titer 1:640
Result (+) Positive
Titer 150.3 U/ml
Hospital Week 4 (Feb. 6 – Feb.12, 2018)
S O
Feb 6: Vital Signs
BP: 110/70
HR: 100
RR: 24
T: 37.5 – 38C
(+) distinct disc border,
yellow disc, whitish
lesion, right eye, inferior
to the optic nerve; (-)
haemorrhage/exudate
Feb10: UO: 0.76cc/kg/hr
A P
• T/C Systemic Lupus • Referred to
Erythematosus Ophthalmology for
• Hospital Acquired dilated fundu exam at
Infection bedside
• T/C Rapidly Progressive
Glomerulonephritis
• MR mild, TR mild,
prob. sec. to SLE
carditis
 CBC – Feb 11
WBC 8.14
RBC 3.15
Hgb 89
Hct 0.246
Feb 12
Platelet 71
Albumin 2.46 (L) 3.50 – 5.00 g/dl
Neutrophil 87.6
Lymphocyte 8.1
Monocyte 4.1
Eosinophil 0.1
Basophil 0.1
Hospital Week 5 (Feb. 13 – Feb.19, 2018)
S O A P
Feb14: afebrile Vital Signs: stable • T/C Systemic Lupus • Meropenem and
Erythematosus Vancomycin
• Hospital Acquired • For TB work-up
Feb18: (-) active bleeding; (+) rales at right lower Infection • follow up sputum AFB
(+) oral ulcers; (-) rashes, lung field • T/C Rapidly Progressive x2
(-) seizure, (-) cough Glomerulonephritis • repeat CXR-PAL
• MR mild, TR mild,
prob. sec. to SLE
carditis
Culture and Susceptibility Result – Feb 17
Urinalysis - Feb 19
Final Report: Positive for Cryptococcus Laurentii after
Color Yellow
20 hours of incubation. Sensitivity nit available.
Transparency Cloudy
Specific Gravity 1.015
pH 5.0
Glucose Negative
Protein 3+
RBC 100+
WBC 16-25
Squamous Epithelial Cells MODERATE
Mucus Threads RARE
Bacteria RARE
Hospital Week 6 (Feb 20 – 26, 2018)
S O A P
Feb20: Vital Signs • Error of refraction, • Given Salbutamol
BP: 100/60 chalazion L eye • No ophthalmologic
HR: 90s • T/C Systemic Lupus intervention
RR: 24 Erythematosus
T: 37.5 – 38.2C • Hospital Acquired
Infection
• T/C Rapidly Progressive
Feb22: Desaturation 80% Glomerulonephritis • Pt. was put on
(+) alar flaring, ECE, (+) • MR mild, TR mild, mechanical ventilator;
rales at LLF prob. sec. to SLE • Given diazepam 10mg
carditis for the seizure
Feb 23: (+)wheeze/rales
(+) frothy secretions,
(+)episode of seizure with
upward rolling of
eyeballs, stiffening of
extremity
Hospital Week 6 (Feb 20 – 26, 2018)
S O A P
Feb 25: (+) facial swelling • Pulmonary Congestion
(+) pallor sec. to fluid overload
ETT secretions, • T/C Systemic Lupus
nonbloody Erythematosus
• Hospital Acquired
UO: 1.1cc/kg/hr Infection
• T/C Rapidly Progressive
Glomerulonephritis
• MR mild, TR mild,
prob. sec. to SLE
carditis
Hospital Week 7 (Feb 27 – Mar 5, 2018)
S O A P
Mar2: (+) blood-tinged Vital Signs • Pulmonary Congestion • received pt. from HD
ETT secretions and NGT BP: 130/80 sec. to fluid overload - • for PT, APTT
drainage HR: 85 resolving
O2Sat: 99% • T/C Systemic Lupus
- Strong pulses Erythematosus
UO: 1.1cc/kg/hr • Hospital Acquired
Infection
Mar3: (+) coffee-ground Vital Signs • T/C Rapidly Progressive • Shifted Meropenem to
NGT drainage BP: 130/80 Glomerulonephritis Cefepime 2g IV drip
(+) puffy eyes HR: 90’s • MR mild, TR mild, q8h ANST
T: 38.5 prob. sec. to SLE • Amphotericin B
carditis 50mg/10ml
• NPO temporarily
• Cont Furosemide drip
• Repeat blood C/S,
CBC, Electrolytes, ABG
Hospital Week 7 (Feb 27 – Mar 5, 2018)
S O A P
Mar4: (+) pallor; (+) fever; General Survey: asleep • T/C Systemic Lupus • Start IVF of PNSS 1L +
(+) coffee-ground NGT but arousable, intubated Erythematosus 40meqs KCl @ 79cc/hr
drainage • Hospital Acquired or 20gtts/min
Vital Signs Infection • Dec. Kabiven rate to
BP: 128/77 • T/C Rapidly Progressive 10cc/hr or 3gtts/min
HR: 114 Glomerulonephritis • Revise Furosemide
RR: 23 • MR mild, TR mild, @5cc/hr
O2Sat: 97% prob. sec. to SLE • Hold K-lyte
carditis • Start Omeprazole
- Equal breath sounds, 40mg IVTT OD
not labored
- Strong pulses, CRT
<2secs
Hospital Week 8 (Mar 5 – Mar 11, 2018)
S O A P
(+) abdominal pain • T/C Systemic Lupus • Reintroduction of
Erythematosus feeding @ 200ml
• Hospital Acquired • IVF: D5 0.45% NaCl
Infection @20gtts/min
• T/C Rapidly Progressive • For crossmatching of
Glomerulonephritis blood
• MR mild, TR mild, • For stat HD (HD#4)
prob. sec. to SLE with blood transfusion
carditis of at least 1unit of
PRBC
Hospital Week 8 (Mar 12 – Mar 18, 2018)
S O A P
Mar12 – 14 Vital Signs • T/C Systemic Lupus • Continue 400ml of
(+) pressure ulcers BP: 100/58 Erythematosus blenderized feeding
HR: 107 • Hospital Acquired q4hrs
RR: 22 Infection • IVFTF: D5 0.45%NaCl
O2Sat: 96% • T/C Rapidly Progressive 1L @ 20gtts/min
Glomerulonephritis • Discontinue Amikacin
- (+) pupils equally • MR mild, TR mild, • Labs: Repeat blood
round reactive to light prob. sec. to SLE C/S x 2sites; S. Mg;
- strong peripheral carditis Procalcitonin
pulses • Refer to CECAP for HIV
testing

Mar15 - (+) labored breathing • Re-intubated

ETT secretions bloody • Vit. K 1amp stat dose
after coughing
Culture and Susceptibility Result – March 16
Final Report: Positive for Burkholderia cepacia after 17 hours of incubation.
Hospital Week 9 (Mar 19 – Mar 25, 2018)
S O A P
Mar 19 Vital Signs • T/C Systemic Lupus • IVF: D5LR 1L @
(+) coffee-ground BP: 110/60 Erythematosus 22gtts/min
drainage on NGT HR: 120 • Hospital Acquired
RR: 34 Infection
O2Sat: 96% • T/C Rapidly Progressive
Glomerulonephritis
Pre-extubation • MR mild, TR mild, • Extubated pt.
BP: 110/70 prob. sec. to SLE • ABG taken
HR: 127 carditis • Feeding reassessed
RR: 27 after 4hours
O2Sat: 94-95%

Post-extubation
HR: 125
RR: 32
O2Sat:95 – 96%
CBC – Mar 19
WBC 7.87
RBC 3.09
Hgb 88
Hct 0.25
Platelet 135
Neutrophil 92.4
Lymphocyte 6.2
Monocyte 1.3
Eosinophil 0.0
Basophil 0.1
CBC – March 21
WBC 7.87
RBC 3.09
Hgb 88
Hct 0.25
Platelet 135
Neutrophil 92.4
Lymphocyte 6.2

Monocyte 1.3
Eosinophil 0.0
Basophil 0.1
Hospital Week 9 (Mar 19 – Mar 25, 2018)
S O A P
Mar22 • T/C Antibiotic- • Labs: ABG POC stat;
(+) watery-stools, Associated Diarrhea Stool Exam; Stool C/S;
yellowish, non-foul with Mild Dehydration S. Electrolytes stat
smelling • O2 via face mask @
10LPM
• High-back rest
• Cotrimoxazole 1tab
BID per NGT
• Start Probiotics
Hospital Week 9 (Mar 19 – Mar 25, 2018)
S O A P
Mar23 unresponsive • T/C Systemic Lupus • CPR started
Mother refused Vital Signs Erythematosus • Manual ambubagging
intubation HR: 59 • Hospital Acquired • Suction secretions PRN
(+) copious oral secretions O2Sat: 39% Infection • Epinephrine 1amp
(+) desaturations • T/C Rapidly Progressive IVTT
Glomerulonephritis
(+) CP arrest • MR mild, TR mild,
prob. sec. to SLE
carditis
Hospital Week 9 (Mar 19 – Mar 25, 2018)
S O A P
Mar 24 Vital Signs • T/C Systemic Lupus • CPR started
(+) pooling of secretions HR: 59 Erythematosus • Manual ambubagging
O2Sat: 64% • Hospital Acquired • Suction secretions PRN
Infection • Epinephrine drip
(+) decreased air entry • T/C Rapidly Progressive • Dobutamine drip
Glomerulonephritis • Patient revived
• MR mild, TR mild, • For stat HD
prob. sec. to SLE • Repeat blood C/S
carditis
Hospital Week 9 (Mar 19 – Mar 25, 2018)
S O A P
Mar 25: (+) referred for GCS: 5 • T/C Systemic Lupus • CPR started
bradycardia; (+) coffee- Erythematosus • Epinephrine 1ml X
ground NGT drain; Vital Signs • Hospital Acquired 1dose q3mins
HR: 40’s -> 130’s Infection • Resume epinephrine
O2sat: 30% • T/C Rapidly Progressive drip
Glomerulonephritis • Continue Dobutamine
- Pupils 3mm, isocoric, • MR mild, TR mild, drip
sluggish prob. sec. to SLE • Manual ambubagging
carditis • For stat HD
Hgt: 59 mg/dl • Given NaHCO3 50mcg
+ equal amount of
D5W to run over
30mins X 2cycles; to
give 2nd cycle after
30mins
Hospital Week 9 (Mar 19 – Mar 25, 2018)
S O
Mar25 6:25pm HR: 0
(+) fixed dilated pupils
(-) respiration
A P
• T/C Systemic Lupus • Pronounced clinically
Erythematosus dead
• Hospital Acquired • Family consented for
Infection autopsy
• T/C Rapidly Progressive
Glomerulonephritis
• MR mild, TR mild,
prob. sec. to SLE
carditis
CBC – March 24 March 24
WBC 5.4 Creatinine 3.26 0.66 – 1.09mg/dl
RBC 1.8 BUN 64.69 7.87 – 21.90mg/dl
Hgb 51
March 24
Hct 0.157
Sodium 148.2
Platelet 83
Potassium 3.98
Neutrophil 80.7
Chloride 111.0
Lymphocyte 17.4
Ionized Calcium 1.07
Monocyte 1.7
Eosinophil 0.2
Culture and Susceptibility Result
Basophil 0.0
Final Report: No important enteropathogen isolated
Fecalysis – March 24
Color Yellow
Consistency Mucoid
RBC 2-4
Differential Diagnoses

Henoch Schoenlein Purpura

Acute Rheumatic Fever
Juvenile Idiopathic Purpura
Systemic Lupus Erythematosus
Henoch Schoenlein Purpura

HSP is an acute immunoglobulin A-

mediated disorder characterised by a
generalised vasculitis involving the small
vessels of the skin, the gastrointestinaltinal
tract, the kidneys, the joints and rarely, the
lungs and the CNS
Acute Rheumatic Fever

ARF is a multisystem disease resulting from an

autoimmunereaction to infection with Group A
Streptococcus.
Juvenile Idiopathic Arthritis

JRA is the most common chronic

rheumatologic disease in chronic diseases of
childhood. The etiology is unknown and the
genetic component is complex. Patient
usually manifests with joint.
Systemic Lupus Erythematosus

SLE is an autoimmune disease in which

organs and cells undergo damage initially
mediated by tissue-binding autoantibodies
and immune complexes.
 HSP ARF JIA SLE

Fever x x x x
Headache x x

Rash x x x x

Abdominal Pain x x

Vomiting x x

Arthritis x x x

Carditis x x

Subcutaneous Nodules x x

Chorea x x

Lymph Node Enlargement x x

 HSP ARF JIA SLE

hepatomegaly x x

splenomegaly x x

serositis x x

edema x

seizure x

thrombocytopenia x

leukopenia x

valvular involvement x x
nephritis x x x
Impression
1. Multiple Organ Failure secondary to Septic Shock
secondary to Multiple Opportunistic Infections (A. baumanii,
K. pneumoniae, E. faecium, C. laurentii, B. cepacia)
2. Systemic Lupus Erythematosus
3. T/C Immunocompromised State
4. S/P Intubation
5. S/P Arrest x12
Mechanism of Organ Damage
Right Lung
Heart
Kidneys
Kidneys
Stomach
Pancreas
Liver
Appendix
Provisionary Anatomic Findings:
1. Brain
• Grossly unremarkable
2. Heart
• Left Ventricular Hypertrophy
• Ventricular Septum (3cm)
• Left Ventricular Wall (1.5cm)
• Pericardial Fluid (75ml)
3. Lungs
• Pulmonary Congestion, Bilateral
• Multiple yellow to green solid nodules (0.5 to 2cm in diameter), bilateral
Provisionary Anatomic Findings:
4. Abdomen
• Peritoneal Fluid (400ml)
• Hepatomegaly (1950 grams)
• Splenomegaly (200 grams)
• Grossly unremarkable: Stomach, Pancreas, Small and Large Intestines,
Appendix
5. Kidney
• Grossly enlarged (400 grams), Bilateral
• End