Case Presentation: A young girl with Ascites

Syed Hussain Azhar Medical IV CHK

17 Jan, 2011

Case Presentation

History
A 13 years old girl, unmarried, resident of Malir, admitted via OPD with the complaints of:
Progressive Abdominal Distention ------5 years Increasing Swelling of Face and feet ----- 1 week Productive Cough and Shortness of Breath- 1 week

History of Presenting Illness

According to the patient, she was in her usual state of health 5 years back, then she developed a febrile illness with decreased urine output, mild abdominal distention, and cough for which she was put on Tab Deltacortil 5 mg 2 OD and some other medications by a GP. The fever subsided, and the urine output became almost normal, although she continued to take Deltacortil and Aldactone.

History of Presenting Illness contd

She was labeled as Asthmatic on the basis of Cough and wheeze 5 years ago Over the period, the patient has gained weight, with progressive swelling over the lower limbs and face She continued to take the drugs, and did not consult any doctor since then
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History of Presenting Illnesscontd

For the last 1 week, she has complaints of increasing swelling over face and feet, associated with productive cough and shortness of breath Cough is moderate, more at night and on lying down, with yellow sputum and shortness of breath

History of Presenting Illnesscontd

There is no history of fever, PND, dizziness, wheezes or chest pain, any urinary or GI complaints or joint problems She suffered from fever and cough 3-4 years ago, and took ATT for few months and then stopped without completing the course
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Past History
No h/o urinary complaints before, jaundice, blood transfusions, surgery

Menstrual Histroy
Menarche not achieved yet

Personal History
Sleep is disturbed due to cough and shortness of breath Appetite is also reduced Urine output is adequate only if she takes aldactone, otherwise reduced Normal bowel habits No addictions or known allergies

Family History
No h/o any familial disease

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Socio-economic status
Low

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Any Thoughts !

General Physical Examination

A young girl of short stature, with facial puffiness and gross abdominal distention, lying uncomfortably on the bed, appears lethargic and ill, but oriented to time, place, and person BP = 90 / 60 mmHg Pulse= 110 / min Regular R/R = 20 / min Temp = 990 F

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 She has mild pallor, pitting edema over lower limbs till knees Cyanosis, Clubbing, Leuconychia, Palmar erythema, Jaundice, Spider Nevi were absent JVP Not raised Thyroid Not Enlarged Lypmh Nodes Not Palpable

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Abdomen
Distended with central, inverted Umbilicus, no dilated tortuous veins or visible peristalsis, and no stria Soft, non-tender Visceromegaly difficult to appreciate Shifting dullness and fluid thrill present Bowel sounds audible Sacral edema present No CVA tenderness
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Chest
Normal in shape, symmetrical, equally moving with respiration Trachea central Resonant all over, except dull at bases Inspiratory coarse crepts at bases bilaterally with occasional wheezes and reduced air entry at bases Vocal resonance equal
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CVS
All peripheral pulses palpable Apex beat not displaced S1 , S2 audible No added sound

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CNS
Grossly Intact Bulk appeared to be reduced all over Power was 4/5 at hips bilaterally

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Musculoskeletal
Full range of motion in all joints No evidence of swelling, warmth, deformity in any joint

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Summary
A young girl with h/o progressive abdominal distention for 5 years, increasing swelling over face, bilateral pitting edema, shortness of breath and productive cough for the last 1 week. She has been taking Deltacortil 10 mg OD and Aldactone on & off over last 5 years. On examination, she has short stature, cushingoid face, mild pallor, gross ascites with pedal edema. She has bilateral basal coarse crepts without jugular venous distention or hepatomegaly

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Differential Diagnosis

Differential Diagnosis
Iatrogenic Cushings Disease with underlying:
Nephrotic Syndrome Cirrhosis Hypoalbuminemia

Pneumonia / TB

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Investigation
CBC
Hb ---- MCV ---- TLC ---- Platelets -11 gm% 78 fl 10,000/ cu mm 112,000/cu mm

ESR

----- 65 mm in 1st hour

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Investigation contd
Urine D/R (AKU)
Proteins ----- negative RBC / WBC ----- Nil / HPF

UCE

----- WNL

Lipid Profile ----- WNL

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Investigation contd
LFTs INR ----------WNL 1.26 1.8 gm% 3.0 gm%

S. Albumin ----- S.Globulins ------

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Investigation contd
What Next ?

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Investigation contd
Ascitic Fluid D/R
Proteins ----- TLC ----- Neutrophils ----- Lympohocytes --400mg% 100 / cu mm 20% 80%

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Investigation contd
U/S Abdomen
Liver: Coarse Echotexture

Size: 14 cms Nodular margins PV = 0.9 cms

Spleen: Normal Kidneys: Normal Gross ascites with Internal Echoes
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 What Next ?

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Investigation contd
HBsAg ------ Non-Reactive

Anti-HCV Antibody ----- Non-Reactive

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Investigation contd

Sputum AFB D/S ( 3 Samples)

------

Negative

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CXR ( Simulated)

Reporting of Actual CXR

Upper lobe Pulmonary Diversion Pulmonary Perihilar edema Straightening of Left Heart Border Cardiomegaly Infiltrates in lower zones bilaterally

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Investigation contd
What Next ?

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 ECG
Rate = 92/ min Low voltage Right Axis Deviation T wave inversions in V1 V4

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Investigation contd
Echocardiography
Ejection Fraction = 60% Normal size LV High Normal size RV Dilated RA and LA Thickened Mitral Valve with AML No Pericardial Effusion Estimated PAH = 30 mmHg (Conclusion: Rheumatic Mitral valve disease)

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Investigation contd
What Next ?

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Investigation contd
CT Chest Report Chronic inflammatory changes in lower lobes Pericardial Effusion with thickening and calcification Cardiomegaly Bilateral Mild Pleural Effusion (Ascites)

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CT scan showing Pericardial Thickening

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Final Diagnosis
1. Constrictive Pericarditis ( most likely secondary to TB) 2. Resolving Nephrotic syndrome? 3. Pneumonia 4. Iatrogenic Cushings Disease
17 Jan, 2011 Case Presentation

Thank you
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Course in the Ward

Patients edema and ascites did not subside Developed diarrhea Went into (Addisonian +- hypovolemic shock) Expired

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