Case of nephrotic syndrome in a 5 year old child with swelling over eyes, legs and abdomen.

This is the case of a 5 year old child (Patient Ref. No. L-6990) suffering with Nephrotic syndrome. The child is having NS for the last 3 and ½ years ( since when he was only 20 months old ). The swelling was noticed around the eyes, legs and abdomen with recurrence of the symptoms. He was having these complaints once in 5 or 6 months. This happened usually when steroids were tapered off to alternate days at reduced doses.

The frequency of urination and the quantity had decreased considerably. The child had never complained of any pain during urination. (In the early years preceding the diagnosis of NS, the child had complained of burning sensation while passing urine). The color of urine had turned straw colored or yellowish or mustard oil color. The swelling was noticable in the morning. The child felt comfortable by lying on back. He had normally two motions / day. He had alternate diarrhoea and constipation. During the NS condition, the urination decreased considerably.

His father was 35 years old , worked as Inspector of Customs and Central Excise at Cuttack. Had type 2 diabetes Mellitus for the last 2 years. His mother (31) was an active housewife.His brother is only 1 year old. His grandfather (60 years), retired government employee was hypertensive and had recovered from two paralytic strokes.

The child was anxious and obstinate. He desired company. He usually remained playful. However sometimes he used to become restless. He used to get angry when his demands were not met He throws things. He was violent with his younger brother and used to often hit him. He had a fear of dogs and complete darkness. He is fun loving but irritable at times especially when his demands are not met. He has very sharp memory. He does not share his things with others.

He remained on steroid for about 11 months. However after 3 months Traces of albumin were found in his urine. He was prescribed steroids by the nephrologist, which were gradually tapered. However there has been relapses every 6 to 7 months when steroid was tapered gradually. He was on 40 mg dose of steroid (daily dose) as advised by their physician. He was given treatment for 4 months and asked to report after the medicines were exhausted.

His urine reports showed only protein+. No RBC were noticed in the microscopic tests. Ultrasound was done during the period of swelling. USG revealed normal kidneys with free fluids in the abdomen. No hydronephrosis was noticed in the USG.

After a period of 4 months, we received an e-mail from the patient's father saying that the patient was doing absolutely fine. His weight was 28 Kgs. His steroid dose was tapered to 35 mg every alternate day. He was also given calcium everyday. The urine test report showed no protein.

Based on this feedback the treatment was continued on the similar lines and again the second batch of medication was sent to the patient.

After again a period of 4 months, the patient's father reported by e-mail, that he would thank us for the continuous improvement seen in his son's case. His steroid dose was further tapered to 15 mg of prednisolone on every alternate day. No episodes of cold or cough were encountered. He was improving in his studies.

Again after a period of 4 months the father reported that the patient was doing very well with the treatment. The alternate dose of steroid had already been reduced to 5 mg. However due to an episode of cold few of his complaints had recurred. The puffiness of the face was noticed. Also in the morning there was swelling around the eyes. There was slight swelling over the legs. After administration of diuretics, swelling had decreased.

We made some necessary changes in the line of treatment in order to take care of this relapse. We had advised the patient to get investigated for serum albumin and serum cholesterol. The findings were, Serum Albumin: 2.6 G/DL and Serum Cholesterol:445 mg/dl.

Follow up details:
On 2.1.2006 it was seen that his weight had increased from 30 Kgs to 32 Kgs. He was advised lasix injection. On 3.2.2006 he complained of redness on his legs. On advice, he was hospitalized for treatment of cellulitis. The final blood culture report confirmed bacterial infection (streptococcus). He was treated with antibiotics.

He is still on treatment in order to prevent the occurrence of relapses and we aim to bring him off steroids completely over a period of time.

Remark: The remedy prescribed in these cases is patient-specific i.e. it has been prescribed based on the symptoms specific to the patient at that point of time. It is advisable that the patient does not indulge in any self-medication.

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