PEDIATRIC CPC CASE 2022

CASE HISTORY
General Data
J.D. 12-year-old girl from Consolacion, Cebu who was admitted for the first time at a tertiary private
hospital.

Chief Complaint
Discoloration of skin under the eyes and fever
.
History of Present Illness
A 12-year-old girl was brought for consult because of a 10-month history of hyperpigmented
discoloration of the skin under her eyes. Two months prior to hospital admission, she developed
erythema on the tips of her fingers and toes. Swelling of her lips and under her eyes was noted 2 weeks
prior to the evaluation. The patient also noted mild gingival bleeding after brushing her teeth. Her father
reported that she had a 5-day history of subjective fever.

10-month history of hyperpigmented discoloration of the skin under her eyes.

2 months prior to hospital admission - erythema on the tips of her fingers and toes
2 weeks prior to the evaluation - Swelling of her lips and under her eyes
5-day history of subjective fever
mild gingival bleeding after brushing her teeth

Past medical history:

At 5 years old patient had Acute Gastroenteritis with Some Dehydration, was brought at the ER
but was discharged after 4 hours of ORT.
At 10 years old, she had fever and sore throat but was not brought for consult to a physician
(untreated → high risk for rheumatic fever) as they only brought the patient to a traditional healer.
She has completed the basic immunization up to 1 year old as claimed by the mother. The
mother also claimed that she was allergic to shrimp. Patient has no history surgical procedures done.
Developmental milestones were also appropriate for age as what the mother can remember.

Family History:
The patient’s father has asthma. Her paternal grandparents were both hypertensive, while the maternal
grandmother was diabetic. Patient’s uncle on the maternal side died of lung cancer. Patient’s auntie on
the maternal side died at 50 years old with unrecalled diagnosis.

Personal and Social History:

Patient lives with both parents in a 2-storey house made of concrete that is located near the highway.
Father is a certified public accountant while mother is a public school teacher. They own a pet dog and
the child is also taking care of a hamster.
Patient is an only child and is currently a Grade 6 student in a well-known private school. Her diet
consists mostly of fried food especially pork and chicken. She loves to play mobile games and watch
anime.

Review of systems was negative for joint swelling, weight loss, diarrhea, vomiting, or difficulty
breathing.
PHYSICAL EXAMINATION
The patient was alert, cooperative, and in no acute distress.
Vital Signs: Axillary temperature 38.3 degrees Celsius HIGH, pulse 111 HIGH, respiratory rate 20/min
NORMAL, blood pressure 108/65 mm Hg, weight 44.8 kg, height 150 cm, (BMI 19.9) Normal, peripheral
oxygen saturation/room air 98%

HEENT: There was significant swelling of the lips, with erythema and ulceration of buccal mucosa (oral
mucosal ulcers → SLE)

Hyperpigmented skin under both eyes was also noted. (possible malar rash of SLE?)

Oral mucosa was pink and moist, with gingival hypertrophy and minor active gingival bleeding noted.
Cervical lymphadenopathy (Adolescent with persistent fever, tonsillar pharyngitis and cervical
lymphadenopathy 🡪 INFECTIOUS MONO) (1.5-2.0 cm) was observed in the posterior cervical chain
bilaterally.

Cardiovascular: Regular rate and rhythm, 2/6 systolic murmur without rubs or gallops. Chest was clear
to auscultation

Abdomen: Bowel sounds present; liver palpable 2.5 cm below right costal border; spleen palpable
approximately 2 cm below left costal border

Extremities: No edema; multiple small areas of subcutaneous hemorrhage on tips of fingers and toes
were seen.(vasculitic rash → SLE)
LABORATORY RESULTS
CBC with differential:
hemoglobin 10.9 g/L, (low?)
hematocrit 32.4% (low?)
platelets 109 mm3, (low? → bruising, bleeding gums)
total white blood count 3800/mm3 ( →leukopenia?)
41% granulocytes-low NV: 55-75%
2% bands
50% lymphocytes (high) NV: 20-35%
7% monocytes- normal NV: 3-8%
absolute neutrophil count 1.6 mm3 low

Erythrocyte sedimentation rate: 56 mm/hr (if >30 mm/hr → inflammation)

Metabolic profile:
sodium 137 mEq/L, (ok 130–147 mEq/L)
potassium 3.6 mEq/L, (ok 3.5-5.1 mEq/L)
chloride 105 mEq/L, (ok 95-105 mEq/L)
bicarbonate 21 mEq/L, low 22-29
blood urea nitrogen 8 mg/dL, (ok 2–20 mg/dL)
creatinine 0.9 mg/dL, (ok 0.5-1.5 mg/dL)
total protein 8.9 g/dL, (inc? 6.0-8.0 g/dL)
albumin 3.5 g/dL, (ok 3.5–5.6 g/dL)
total bilirubin 0.6 mg/dL, (ok < 1.5 mg/dL)
alkaline phosphatase ALP 102 U/L, (ok 100–420 units/L)
AST 380 U/L, (high? 10–40 units/L)
ALT 162 U/L, (high? 5–55 units/L)
uric acid 3.4 mg/dL, (ok 1–7 mg/dL)
LDH 406 U/L, (high 100-330 units/L)
CPK 500 U/L (high 29-192U/L)

Urinalysis: trace protein, trace leukocyte esterase, 0-2 red blood cells and white blood cells per high-
power field

Blood, urine, and lip lesion cultures yielded negative results

Hepatitis panel negative for hepatitis A, B, and C; parvovirus B19 antibodies negative; Epstein-Barr virus
(may play a role in SLE susceptible individuals) antibody titers reveal past infection.
Chest radiography: small bilateral pleural effusions

Echocardiogram: trace of mitral regurgitation and mitral valve prolapse

CT scan of abdomen: no abnormal findings

Systemic lupus erythematosus in childhood

Increased risk of neisserial infections in systemic lupus erythematosus
Native-valve endocarditis due to Neisseria sicca

PRIMARY DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS:

Disease: Rule in: Rule out:

EBV Splenomegaly,
Hepatomegaly, rash,
pneumonia
WORKING DIAGNOSIS:

1. Create a problem list of the case.

HPI

● a 10-month history of hyperpigmented discoloration of the skin under her eyes

● d erythema on the tips of her fingers and toes
● Swelling of her lips and under her eyes
● mild gingival bleeding after brushing her teeth
● a 5-day history of subjective fever

PMH

● 5 years old patient had Acute Gastroenteritis with Some Dehydration

● 10 years old, she had fever and sore throat but was not brought for consult to a
physician
● allergic to shrimp

FAMILY HISTORY

● father has asthma

● paternal grandparents were both hypertensive
● maternal grandmother was diabetic
● Patient’s uncle on the maternal side died of lung cancer

PERSONAL/SOCIAL

● own a pet dog and the child is also taking care of a hamster.
● diet consists mostly of fried food especially pork and chicken

PE

● Axillary temperature 38.3 degrees celsius (HYPERTHERMIA)

● pulse 111 (TACHYCARDIC)
● significant swelling of the lips, with erythema and ulceration of buccal mucosa
● Hyperpigmented skin under both eyes
● gingival hypertrophy and minor active gingival bleeding
● Cervical lymphadenopathy (1.5-2.0 cm) was observed in the posterior cervical chain
bilaterally
● 2/6 systolic murmur without rubs or gallops
 ● multiple small areas of subcutaneous hemorrhage on tips of fingers and toes

LABS

● UA: trace protein, trace leukocyte esterase

● Epstein-Barr virus antibody titers reveal past infection
● CBC low hemoglobin, low hematocrit, low platelet, leukopenia, with high leukocyte
count and low granulocyte,absolute neutrophil count

2. What are some of your initial impressions/differentials of the case? How would you rule in or
rule out each one of your impressions?
a. SLE
i. rule in
1. Diagnosed in adolescence usually in female, with a median age of
11-12 years old
2. Swelling of the lips, with erythema and ulceration of buccal mucosa
3. Fever, lymphadenopathy
4. Hyperpigmented skin under both eyes
5. Leukopenia
6. Pleural effusion
7. Past EBV infection may play a role
8. Trace of mitral regurgitation and mitral valve prolapse - possible
Libman-Sacks endocarditis which is a potential cardiovascular
manifestation of SLE
ii. rule out
1. (-) weight loss
2. (-) arthritis
3.
b. EBV

Rule in: Splenomegaly, Hepatomegaly, rash, pneumonia

Rule out: (-) weight loss, (-) malaise, (-) organomegaly

3.Children and adolescents with SLE can develop a rash of (almost) any morphology, location and
distribution, often presenting a diagnostic challenge to the primary care physician. A skin biopsy for
histology aids in making the correct diagnosis, although biopsies of facial skin should be avoided.
Additional tests include:

Immunology Testing

ANA, anti–double-stranded DNA, anti-Smith antibody, lupus anticoagulant, and

antiphospholipid antibody panel. Obtain other autoantibodies, which may be associated with specific
disease manifestations, including anti-Ro, anti-La antibodies associated with Sjögren syndrome, and
anti ribonucleoprotein (anti-RNP) antibodies, C3, and C4,.

Staging
staging criteria have been proposed to help assess the degree of illness. Determining which
set of organs is inflamed is useful to decide treatment options