UNIVERSITY OF SANTO TOMAS HOSPITAL
Clinical Division
Espana, Manila
Department of Pediatrics
CLINICAL ABSTRACT
December 22, 2010
Our patient is Thimmie Nicolai Dela Cruz, 4 months old female, from 231 Int 37 Aguadost. San Miguel , Manila, who came at the ERCD with a chief complaint of fever, and was admitted last December 08, 2010, with an admitting diagnosis of Acute pyelonephritis, polycystic
kidney disease vs. multicystic dysplastic kidney disease.
Patient was born to a 25y/o G3P2 (2002), high school graduate, married to a 27 y/o assistant engineer. She had regular prenatal
checkups since 2 months AOG at a local heath center totaling 7 visits. She had intake of Multivitamins but no Folic acid and iron
supplementation. The mother had symptomatic UTI at 6th months age of gestation diagnosed through urinalysis and , she was non-compliant
with Amoxicillin 500 mg/ tablet prescribed and opted to drink Buko juice for 1 ½ months. No repeat urinalysis was done, however she claimed
improvement after 2 weeks. On the day of delivery, the mother had fever (40 o C) accompanied by chills, she was prescribed with Amoxicillin
500 mg/tablet TID, She was non-compliant and was able to take single dose only. The mother was not screened for Hepatitis B and Diabetes
Mellitus. She denies any exposure to radiation, viral exanthems, or drink alcohol during her pregnancy.
Patient was born live, pre-term (35 weeks), singleton, female via NSD attended by an OBGYN at Ospital ng Sampaloc. She had good
cry at birth and with no post-partum complications. Patient had a birth weight of 2.8kg and birth length was unrecalled. Newborn screening was
done which showed normal results. However, no vaccinations were given.
Our patient was admitted for 18 days in our institution last September 14, 2010 because of fever and vomiting. She was assessed to
have Acute renal failure secondary to Polycystic Kidney Disease vs. MCDK, Acute pyelonephritis (candida albicans). She was treated with
Fluconazole for 6 days which was shifted to Amphotericin B IV Infusion (0.5mkd) after laboratory results showed sensitivity to the said antifungal. The patient was then discharged and instructed to give NaHCO3 2 pptabs BID and Cefalexin 1 ml OD.
Two days prior to admission patient experienced fever (39oC) accompanied by vomiting of previously ingested milk (4x) .There were
no accompanying symptoms such as cough, colds and diarrhea. The patient was noted to be irritable, however still with good suck during
feeding. There was no noted decrease in the urine output. The patient was brought to USTH CD where CBC revealed anemia. Serum creatinine
was elevated and urinalysis was suggestive of UTI. The patient was then advised for admission, however due to financial constraints opted to
be managed as out-patient. The patient was discharged against medical advice and was given ORS 45. 1 day PTA, patient was persistently
febrile accompanied by vomiting of previously ingested milk (8x), hence prompting this admission.
On the 1st Hospital day, the patient was immediately started on Cefuroxime 125 mg/IV infusion over 30 minutes every 8 hours,
NaHCO3 650 mg /tab , 1 tab divided into 5 pptab, 2 pptab BID, Paracetamol 100 mg/ml 0.6 ml every 4 hour for temperature greater than 38.5
C. He was also started with D5 0.32 NaCl 500 ml to run at 20-21 ml/ hr. ABG showed metabolic acidosis. CBC revealed microcystic ,
normochromic anemia. Serum Creatinine was 1.42 with ECC of 17 ml/minute/1.72m2 , BUN was 41.88. urinalysis revealed (pyuria at 20-25/hpf)
.On the 2nd HD Iron + Vitamin B complex drops, 1ml OD with 15 mg of elemental iron was also given. Urine creatinine was 9.29mg/dl, with total
protein of 48. 58 mg/dl.
On the 3rd HD referral to Genetics was done for Polycystic Kidney Disease work-up. On the 4th HD urine culture and sensitivity
revealed Klebsiella pneumonia, sensitive to meropenem, Cefuroxime 125 mg/IV infusion was then shifted to meropenem 100mg/ SIVP over 30
minutes every 8 hours. On the 5th HD Milk feeding with NAN-HW 10 oz every 2 hours was started and Meropenem was revised to 100 mg/SIVP
over 30 minutes every 12 hours. On the 7th HD, IVF-TF:D5 IMB 500ml was instructed to run at 20-21ml/hr. She was referred to St. Cosmas and
Damian for financial assisitance. On the 8th HD, urinalysis was done which showed UTI (pus cells 6-10/hpf). At this time the patient was noted
to have a singular erythematous irregularly shaped patch measuring 4.5cm by 8cm located at the inguinal areas extending over to the buttocks.
Zinc oxide and calamine lotion was instructed to be applied thinly over affected areas twice daily.
On the 9th HD, she was administered with0.65% NaCl nasal drops, 3-5 drops/nostril every 6 hours. Repeat creatinine was done
which showed elevated results at 0.94. On the 10th HD, repeat CBC was done which showed microcyotic hypochromic anemia wherein.
Ferrous sulfate drops 0.5ml was resumed to be taken twice daily. ABG was also done which showed metabolic acidosis for which sodium
bicarbonate 650mg/tablet 2 tablets divided into 5 pptablets, 1 pptablet twice daily. On the 11th HD, there was noted increase in mucosal
secretions and harsh sounds appreciated upon auscultation of the chest. Salbutamol nebulization was administered every 8 hours which
provided relief of symptoms.
On the 13th HD, the patient was scheduled for DMSA renal scan. She was referred to Urology for VCUG. It was advised to acilitate
KUB of both parents. On the 14th HD, DMSA renal scan was done. Initial results showed poor protein intake and secretion
Patient was scheduled for DTPA and VCUG to be done the next day.
Noted by:
Dr. J. Macazo, MD
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