Welcome to the ACH PIG Challenge! To answer the questions below please post a comment (which will be sent to us but not published) or email ACHPIGChallenge@gmail.com . We will post answers in mid January when the new case is published. You will be placed in a drawing to win an Atlas of Pediatric Physical Diagnosis by Zitelli and Davis every time you participate!!
Case #1
A 4 year old caucasian little boy, with no significant past medical history, was brought to the emergency department today crying and refusing to walk. 2 weeks ago he had a cold with cough, runny nose, headache, and a lowgrade fever that has since resolved. Today his knees and ankles are swollen bilaterally, without erythema or warmth. He is afebrile. Mom says a rash started 1 to 2 days ago to his lower extremities. On exam, he has a raised rash to his buttocks, legs, and feet, similar to the rash seen below. He weighs 15 kg and his vital signs are within normal limits.
Questions:
1. How often is the rash present with this clinical diagnosis?
This patient has Henoch Schonlein Purpra (HSP). The rash is present 100% of the time. Arthritis is present 75%, GI involvement 50%, renal involvement 25%.
2. The patient’s parents were advised on when to bring the child back, and he was sent home on scheduled ibuprofen for the pain and swelling. He returns to the emergency department a few days later with refusal to take po secondary to abdominal pain. On exam he is obviously dehydrated; he has sticky mucous membranes, deepset eyes, and tachycardia. You would like to bolus him. How much will you give and what solution?
You should bolus 20ml/kg of an isotonic solution- In this case 300mL Normal Saline or Ringer’s Lactate- over 30 minutes to 1 hr or faster (IV push) if the kid is unstable or looks to be in shock
3. What GI complication is associated with this condition and is characterized by colicky abdominal pain and blood in stool? What diagnostic test(s) could you use for this diagnosis if suspected?
Intususception (submucosal and serosal hematomas may act as a lead point)- You can diagnose this with an abdominal ultrasound, but air-contrast enema can serve as a diagnostic tool and potential treatment- if you are unable to reduce it with an air-contrast enema surgery will be necessary for reduction- the surgeon’s are usually on stand-by during the air-contrast enema because of risk of perforation.
4. What screening lab test would you do to check for renal involvement? And what abnormalities would you expect to see if this were the case?
Urinalysis- hematuria/proteinuria
5. GI, Renal, and CNS vasculitis may respond to what treatment?
systemic corticosteroids
