Paciente 1: Glomerulonefritis

Patient 1: Glomerulonephritis

This is a case from last week…

A 3-year-old girl was brought in by her mother for a growing belly. The mother reports that she realized last week that for the preceding three weeks the girl had been eating the veins of the leaves of the jocote plant (Wikipedia says the plant is also known as Red Mombin or Hog Plum). She is concerned because for the last week, in addition to complaining about abdominal pain, the girl has had coffee-ground stools with blood in them.

From across the exam room I can see a little girl the size of a 2-year-old but with a markedly distended abdomen, very thin golden tinted hair. My first thought was that the jocote might be some hepatotoxin and she had developed hepatomegaly and liver failure.

As I begin to examine her, I find her belly to be soft and non-tender and her liver to be only slightly enlarged, if at all. But I notice she has suprapubic swelling and I look to her eyelids which are also slightly swollen. Then I find pitting edema on her legs. Mom tells me that last week, she began to notice the lower abdominal swelling and wondered if it might indicate a urine infection.

I also notice the girl is covered with a scabies-like rash and several bleeding, excoriated lesions on her head that appear super-infected. Her hair is remarkably thin and coarse. I ask mom if anyone else at home has a rash like this and she tells me that all 7 have a terrible itchy rash and mom shows me the lesions on her own arm.

At this point, I’m thinking the girl has scabies and impetigo but I’m also concerned about severe malnutrition given her swelling, thinning pale hair, and small size. I plot her out and, despite her swelling, she plots on “curva bajo” or what we know as 5th percentile. I also think she likely has amoebic dysentery or bacterial diarrhea (given the blood stool) or a large worm load (given the distended abdomen). I send the mom for a urine and stool analysis.

She returns with the results: Entamoeba Histolytica as well as mucous and blood in the stool. However the urine is more concerning. It has blood, protein, and 10-12 WBC/HPF. I realize the girl likely has glomerulonephritis. Mom denies that she’d had a pharyngitis within the last few weeks so I assume it came from a strep infection of one of her many skin lesions.

I check her blood pressure and it is 130/80! I let mom know that I’m now very concerned that her daughter has kidney inflammation and she tells me then that she did have cola-colored urine a week before. I let the mother know I was very concerned that the child’s high blood pressure my cause more problems or get worse so I would like to admit her to the hospital. While admission is free, mom lets me know that she can’t stay in the hospital today because mom is currently nursing an infant sibling and lives 40 minutes away in the town of Patulul. She wonders if the girl’s dad could come back with her tomorrow.

I reluctantly agree, knowing there really is no other option. I advise that the girl take it easy and limit her liquid intake until she returns the next day and let them know they need to come back urgently if she is acting unusual.

I prescribe her 1) TMP/SMX for the skin infections + possible urine infection (>5 WBC/HPF is treated as UTI here given the lack of cultures) 2) metronidazole for the stool infection 3) permethrin 5% cream for the whole family along with advise on clearing it from the beds and sheets (a Herculean effort here, given the lack of washing machines, the need to use firewood to heat water, not to mention a fear of fading the skirts with the hot water).

And that’s the last I saw of this little girl. She did not make it back to see me the next day….or the day after….or the day after that. I imagine, her glomerulonephritis resolved uneventfully but I can’t help but wonder about how she will do in the coming years given her terrible malnutrition and the family’s clear lack of resources.