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Case Report

南區 小兒腎臟學術研討會. Case Report. 高雄榮總 兒童醫學部 邱益煊. Patient General Data. Name: 邱小妹 Age: 13 Y/O Gender: Female Address: 高雄市 Date of admission: 2009/03/23 Date of Discharge: 2009/04/3. Chief complaint.

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Case Report

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  1. 南區小兒腎臟學術研討會 Case Report 高雄榮總 兒童醫學部 邱益煊

  2. Patient General Data • Name: 邱小妹 • Age: 13 Y/O • Gender: Female • Address: 高雄市 • Date of admission: 2009/03/23 • Date of Discharge: 2009/04/3

  3. Chief complaint • Diffuse hair loss and eyebrow hair loss、body weight loss、 and easy fatigue for about 6 months

  4. Present Illness • Diffuse hair and eyebrow hair loss in recent 6 months • Body weight loss from 58 kg to 51 kg in recent 6 months • Easy fatigue and diffuse erythema on eyebrow area in recent 6 months • Mild puffy eyelids and decrease of activity, poor appetite in recent 2 weeks • Feverand neck lymphadenopathy for 3 days • She was taken to our Ped Hema clinic and was admitted for further evaluation

  5. Past history and Family history • Past history: history of atopic dermatitis • Family history: Denied history of autoimmune disease

  6. Physical Examination • VITAL SIGNS: BP： 116 / 87 mmHg, PR： 130 /min, RR： 24 /min, BT： 38 ℃ • BW: 51 kg, BL: 163 cm • CONS: alert, chronic ill looking, activity: poor • Eye: conj.: not injected, not anemic, sclera: no icteric, mild puffy eyelids • Throat: mild injected, painless ulcers over hard palate • Face: malar rash (-), but papular lesions over frontal area and scalp • Neck: multiple LAP(+), over bil. Neck, max. size 1 x 1 cm, movable • Chest: symmetrical expansion, BS clear • HEART: RHB, no murmur • ABDOMEN: soft and flat, normoactive bowel sound, no tenderness, hepatomegaly, 1 cm below RCM, no splenomegaly • Extremity: freely movable, no pitting edema, no acrocyanosis, Raynaud’s phenomena (-) • SKIN: eczema over left ear auricle、Lt temporal area、and bil. Eyebrow, petechiae over both lower limbs

  7. Laboratory at OPD (3/20)

  8. Laboratory at OPD (3/20)

  9. Tentative Diagnosis • R/O SLE • Impaired liver function

  10. Plans to Do: • C3, C4, antiphospholipid Ab, anti-ENA Ab, Coombs tests • Hepatitis markers , PT, APTT, liver function, biochemistry • U/C, B/C • 24 hours urine for Ccr and Protein • Upper abdominal sonography • Record I/O, BP, BW • MTP pulse therapy if definite Dx

  11. Laboratory Data

  12. Laboratory Data

  13. Laboratory Data

  14. Laboratory Data

  15. Sonography • Liver: negative finding • Gall bladder: thickening of the wall with sludge • Kidneys: increased echogenicity of both kidneys, normal size of kidneys • Spleen: normal appearance • No ascites, no pleural effusion

  16. SLE Diagnosis Criteria

  17. Hospital Course • MTP pulse therapy: • 1 gm qd since 3/24, for 3 days, then taper gradually • Plaquenil 1# qd, Keflex 500 mg qid (U/C: e. coli), Urso 1# tid • Activity good, appetite improved, facial rashes improved, oral ulcers improved

  18. Hospital Course OPD

  19. Hospital Course

  20. Final Diagnosis • SLE • Lupus Nephritis • Acute hepatitis

  21. Discharge • 4/3 • Medications: • Prednisolone 3# bid • Hydroxychloroquine 1# qd • Urso 1# tid • Myfortic acid 1# bid • Keflex 1# qid

  22. Discussion • Treatment for the Acute hepatitis with high GGT? • Renal biopsy? • Done or not at this point: normal U/R and renal function

  23. 謝謝您的參與!

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