correct
This patient has nephrotic syndrome complicated by primary peritonitis. Nephrotic syndrome or nephrosis has numerous possible causes and can affect all age groups. The pathophysiology of nephrotic syndrome results in the liver compensating for urinary protein loss by increasing the synthesis of albumin and other molecules. This includes LDL and VLDL and lipoprotein (a), which contributes to the development of lipid abnormalities. The loss of inhibitors of coagulation in the urine such as antithrombin-3 and increased synthesis of procoagulatory factors by the liver causes a hypercoagulable state. Both arterial and venous thrombi can develop in the major vessels. The risk of thrombosis is increased by overly aggressive diuretic therapy.
The signs and symptoms of nephrotic syndrome include high protein levels in the urine, low serum albumin levels, high cholesterol and edema. The edema is due to a decrease in oncotic pressure from the hypoalbuminemia as well as a primary defect in sodium excretion. Some outward symptoms can include difficulty with or a decrease of urination, frequent accidents, swelling of the ankles, fingers or face. Some boys may have swelling of the penis and the scrotum while girls may have swelling of the labia. Several different kidney diseases can cause the syndrome, the most common of which is called minimal change nephrotic syndrome. This condition accounts for about 80% of all cases of nephrotic syndrome occurring in children less than ten years of age.
The complications of nephrotic syndrome include fluid retention, peritonitis and thromboembolism. Ascites or pleural effusions may lead to respiratory difficulty. Scrotal edema can result in skin breakdown and infection. Management consists of intravenous infusion of albumin along with furosemide.
Patients with nephrotic syndrome are also at increased risk of infection due to loss of immunoglobulins and compliment in the urine. Children are at high risk for peritonitis during the period of heavy proteinuria. The most common causative organism is Streptococcus pneumoniae; less commonly, Gram negative organisms such as Escherichia coli are involved. Untreated peritonitis can lead to septicemia, meningitis and death. Primary peritonitis may also occur and is seen almost exclusively in patients with pre-existing ascites - especially those with cirrhosis or nephrotic syndrome. The symptoms and signs vary but fever, abdominal pain and tenderness are common.
Peritonitis should be suspected in any child with nephrotic syndrome who has abdominal pain or tenderness. Paracentesis can be performed to obtain a specimen for cell count, Gram stain and culture after which broad spectrum antibiotic therapy can be initiated.
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patient with abdominal pain and proteinuria
A four-year old presents to the emergency department with complaints of fever and diffuse abdominal pain. He has swollen eyes and penoscrotal edema. The emergency physician suspect perforated appendicitis. His lab values include a white blood cell count of 16,000, C-reactive protein of 10 and a urine which is nitrite negative but has 3 + protein.
Which of the following statements about this patient with abdominal pain and proteinuria is true?
A this patient will not benefit from albumin or diuretics
B peritoneal cultures will probably grow a Pseudomonas species
C interval appendectomy in six to eight weeks will be appropriate
D his cholesterol will be normal
E he may be hypercoagulable
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