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APPROACH TO CHILD WITH GENERALIZED EDEMA
By : Ahmed BahamidPediatric resident @ Alsabeen
hospital
December, 9th,2012
History
- 19 months-old Yemeni boy from Dhamar
- C/O;- Generalized body swelling 3
months
Cont. Hx.
- History of present illness started- 3 months earlier- Gradual onset swelling- 1st in the eyelids (puffy eyes) & LL- Progressive in course- Seen in private clinics several times
but no settled dx where made- Ŕ by diuretics with temporary relief
of edema.
Cont. Hx.
- The swelling eventually involve the entire body
- Face + abdomen + genetalia + LL- Last 2 weeks - Yellowish discoloration of the sclera- Associated with low-grade fever
Review of systems
Positive hx & Negative hx- General; decreased activity, poor
feeding, & Wt gain- Skin; yellowish discoloration, itching of
the scalp + hands + umbilicus, - Cardiac; sweating and tiring with
feeding, dyspnea started @ 3 months of age
- Respiratory; prolonged cough started @ 3 months of age and subsided with the start of recent complain
Cnot…- GIT; anorexia, nausea, vomiting, No
diarrhea with normal daily bowel motion and normal color.
- Genito-urinary; No difficulty with urination, No hematuria, No frothy urine, ONLY decreased urine output
- CNS; only irritability, NO abnormal movement, NO fits, or seizures, or weakness
Cnot…
- Hematological; only pallor, NO hx of skin rash, bruises or bleeding
- Musculoskeletal; No joint swelling or pain
PMHx
- No hx of similar attack- Hx of fever with skin rash twice @
age of 3 months & 6 months- Hx of prolonged cough since 3
months of age treated several times @ private clinics as chest infections but no admissions
- No hx of operations, trauma, allergy or ch. Medical diseases
Pregnancy & neonatal hx
- Product of FT, NSVD @ hospital.- Pregnancy with antenatal care with
no major problems- No perinatal complications- Average birth weight- No cyanosis or jaundice, NO neonatal
resuscitation or admissions-
Nutritional hx
- Exclusive breast feeding in 1st 3 months
- Bottle feeding started @ 4 months of age with adequate amount & concentration(fabimilk formula 1 & 2) besides breast feeding ( till 9 months)
- Formula changed to Nido milk & 10 months of age
- Weaning started @ 8 months of age with rice, cheese, & biscuits.
Immunization & developmental hx
- Immunization hx up-to-date except the last measles dose
- Developmental hx appropriate as his previous siblings (but motor development decreased markedly with the recent disease)
Family Hx
55y
33y
18y
17y
2y
14y
12y
11y
8y19 m
Father (DM & HTN) & smokerMother ( 1 abortion, No still births3rd girl sibling died @ 2y of age from ch. GE + vomiting with ricketsOther siblings healthy, no similar condition or renal disease in the family
Physical Exam
• Conscious, irritable, looked ill, mild RD• Afebrile, pallor & jaundiced• Generalized edema (face + abdomen + LL +
genitalia)
• Vital signs- Heart rate (116 bpm)- RR (48 cpm)- BP (80/40 mmHg)- Temp. (36.3C, axillary)
Cont. P/E
- Growth • Weight 11 kg on admission (50th
percentile) now 11.6 kg• Length 77cm (10th percentile)• HC 48.5 cm (75th percentile)
Pictures of the edema
Cont. P/E
- HEENT• Head; Closed Ant. Fontanelle• Eyes; yellowish sclera + pale
conjunctiva, puffy eyes• ENT; NAD- Neck; diffuse swelling of soft tissues but
no congested neck veins., no significant LN enlargement
Cont. P/E
Chest: normal shape, good air entry bilaterally, normal vesicular breathing, no added sounds.
CVS: not visible apex beat?? & barely palpable,
S1 + S2+ distant heart sounds- pulses: rapid weak pulses, equal- Capillary refill 4 seconds with cold
extremities
Cont. P/E
- Abdomen: 1- inspection; distension, no scars or
dilated veins, everted slit shape umbilicus
2- palpation; tense, no tenderness, wall edema, hepatomegaly (liver 12 cm BCM, span 15 cm) firm-to-hard in consistency, not tender, round border.
3- percussion: +ve shifting dullness & transmitted thrill.
4- auscultation: +ve bowel sounds
Cont. P/E
- Genetalia: scrotal swelling with +ve transillumination
- Back: pitting sacral edema
- CNS; NAD- LL; petting edema, level just below the
knee
- LN; no significant LN enlargement- MSS; no joint swelling or tenderness
Summary
- 19 months-old-boy- Tired and sweating on feeding started @ 3
months of age- Recurrent chest infection started @ 3
months of age- Swelling started periorbital & in LL, then
became generalized (last 3 months)- Jaundice & low-grade fever (last 2 weeks)- O/E; looks ill, mild RD, generalized edema +
huge hepatomegaly + ascites + pallor + mild jaundice
Differential diagnosis
1- Renal - Nephrotic syndrome - Acute GN 2- Hepatic - ch. Active hepatitis (viral infection) - metabolic ( Gaucher disease, Nieman-
pick disease, Wilson disease, GSD type IV)
- chronic liver failure - malignancy (primary/secondary)
Cont… D/Dx
3- cardiac - CCF - constrictive pericarditis - restrictive cardiomyopathy - tricuspid valve disease4- others - veno-occlusive disease - Budd-Chiari syndrome - superior vena cava thrombosis - cystic fibrosis
Investigations
- CBC; - Hb% 7.2 g/dl - PCV 22 - WBC 12.8 - Neut 50 % - Lymph 42 % - Mono 4 % - Eosin 4 % - Platelets 134,000
cont… investigations
- CRP: +ve (2+)
- RFT: (N) urea 16 mg/dl, creatinine 0.6 mg/dl
- LFT: T.protein 5.1 g/dl, albumin 2.7 g/dl, TSB 6.7 mg/dl, SGOT 72 U/L
- RBS: 78mg/dl- Electrolytes: Na 112 mmol/l, K 5.2
mmol/l, Ca 6.7
cont… investigations
- Urine analysis: Normal
- Chest X-ray: globular cardiac shadow enlargement
-
D/Dx
1- cardiac - CCF - restrictive cardiomyopathy - constrictive pericarditis2- hepatic - ch. Active hepatitis (viral infection) - metabolic ( Gaucher disease, Nieman-pick
disease, Wilson disease, GSD type IV) - chronic liver failure - malignancy (primary/secondary)
Cont… D/Dx
3- Renal - Nephrotic syndrome - Acute GN
4- others - veno-occlusive disease - Budd-Chiari syndrome - superior vena cava thrombosis - cystic fibrosis
Abdominal U/S:
- Marked hepatomegaly, smooth surface, no focal lesion
- Signs of dilated IVC & hepatic veins- Bilateral pleural effusion- Partial collapse of Rt. Lower lobe- Marked pericardial effusion- Marked ascites
Abdominal CT- scan
- Markedly enlarged liver- Retrograde filling of dilated IVC & hepatic
veins, with no signs of thrombotic changes or obstructing agent, reflecting passive hepatic congestion related to cardiac cause
- Large amount of ascites- Prominent dilatation of both atrium with
relatively small ventricles & mild to moderate Rt. Sided pleural effusion
D/Dx
Cardiac 1- restrictive cardiomyopathy?2- constrictive pericarditis?
Echocardiography
Picture of restrictive cardiomyopathy with congestive heart failure
Treatment & hospital course
- Ampicillin , IV 500mg QID- Captopril, oral, 6.25 mg BID- Lasix, IV, 10 mg BID- Vitamin K, IV, 5mg single dose
- Definitive treatment: heart transplantation
Approach to a child with edema
Definition & background Pathophysiology Causes Clinical approach investigations Management of edema
Definition and background of edema
Accumulation of excess interstitial fluid and could be localized or generalized.
Edema results from either excess salt &
water retention or from increased transfer of fluid across the capillary membranes.
Understanding of the Pathophysiology of
edema is important in the clinical approach and management of this condition in children.
Cont. definition and background…
Distribution:1- Anasarca; gross, generalized edema with
profound subcutaneous tissue swelling.2- Localized edema; does not reflect a
sustained impairment in the ability to maintain normal Na balance.
3- Special forms of fluid collections in the different body cavities
Hydrothorax (in pleural cavity) Hydropericardium (in pericardial cavity) Ascites (in peritoneal cavity)
Pathophysiology
Generalized edema can arise via two different processes;
Reduced intravascular volume leading to Na & water retention → under-filling edema
Na & water retention secondary to
expanded plasma & intracellular tissue fluid volume accompanied by lack of natriuresis → over-filling edema.
Cont. Pathophysiology…
Mechanism of under-filling edema Initiated with ↑↑ glomerular permeability to
albumin → albuminuria → hypoalbuminemia → ↓↓ plasma oncotic pressure → movement of water from intravascular space to the interstitium.
The contracted intravascular volume→↑↑ RAA activity +↑↑ SNS activity + ADH release
These factors→ water & Na retention→ further ↓↓ plasma oncotic pressure→ setting up a vicious circle
Cont. Pathophysiology…
Mechanism of over-filling edema Resulting from expanded
extracellular volume that results from primary renal Na retention, possibly secondary to the renal damage.
In over-filling edema the RAA system & SNS & ADH secretion are depressed.
Causes of edema
Causes of edema according to physiological changes:
Increased hydrostatic pressure Decreased plasma oncotic pressure
(hypoproteinemic states) Increased capillary leakage Impaired lymphatic flow Impaired venous flow
Cont. Causes of edema according to physiological changes…
1- Increased hydrostatic pressure Acute nephritis syndrome Acute tubular necrosis Cardiac failure-low output (CCF) Cardiac failure-high output
(hyperthyroidism, anemia, beriberi) Arteriovenous fistula Acute and chronic renal failure Constrictive Pericarditis & restrictive
cardiomyopathy
2- Decreased plasma oncotic pressure (hypoproteinemic states)
Nephrotic syndrome Chronic liver failure,
autoimmune hepatitis, fulminant hepatic failure
Protein losing enteropathy Protein caloric malnutrition Severe burns
3- Increased capillary leakage Insect bite, trauma, allergy,
sepsis, & angio-edema Vasculitis (anaphylactoid
purpura, SLE, dermatomyositis, polyarteritis nodosa, scleroderma, & Kawasaki disease)
4- Impaired lymphatic flow Lymphatic obstruction (tumor),
congenital lymphedema. Milroy disease in newborn Wuchereria bancrofti infection Post-surgical & post irradiation
5- Impaired venous flow Hepatic venous outflow obstruction,
superior/inferior vena cava obstruction
6- Others Myxedema, Hydrops fetalis, drugs
like NSAIDs, steroids, vasodilators etc…
Clinical approach
Confirm edema Assess distribution of edema:
generalized VS localized edema Detailed history and physical
examination to assess severity, associated complications, and underlying cause of edema.
Clinical approach cont…
Assess distribution of edema generalized VS localized edema
In generalized edema look for pretibial, sacral, scrotal, vulval edema other than periorbital edema and ascites.
Clinical approach cont…
Localized edema Hx. Of trauma, insect bite, or
infection Peripheral lymphedema in female
newborn to exclude Turner’s syndrome
Acute edema of the face and neck to exclude superior vena cava obstruction syndrome.
Clinical approach cont…
B- Generalized edema 1- Renal disease (most common cause in
children) Rapid onset edema, puffiness around the
eyes, gross hematuria, oliguria, hypertension, cardiomegaly, pulmonary edema to suggest acute glomerulonephritis.
Frothy urine suggests nephrotic syndrome. Absence of circulatory congestion
differentiates nephrotic syndrome from nephritic syndrome.
Renal disease cont…
Signs and symptoms of chronic insufficiency such as anemia, growth retardation, and uremic symptoms such as nausea and vomiting.
Exclude secondary causes such as post-infectious glomerulonephritis (history of throat or skin infection in recent past), SLE, Henoch Schonlein purpura (skin rash & joint pain).
Look for symptoms of hypertensive encephalopathy (headache, irritability, confusion, altered sleep pattern, & convulsion).
2- Liver disease
Ask for hx of fever, anorexia, vomiting, abdominal pain, progressive jaundice, fetor hepaticus, bleeding manifestations, clay color stool, black tarry stool, hematemesis, pruritis & abdominal distension.
Stigmata of chronic liver disease such as palmar erythema, clubbing & spider naviae.
HSM with gross ascites in the absence of jaundice to exclude portal vein thrombosis.
Previous operation scar such as Kasai porto-enterostomy.
3- Cardiac disease
Symptoms of CCF such as decreased effort tolerance, orthopnea, paroxysmal nocturnal dyspnea in older children and poor weight gain, feeding difficulties, excessive sweating, bluish episodes and respiratory distress in infants.
Signs of cardiomegaly, gallop rhythm, precordial pulge, pallor, cool extremities, elevated JVP, weak pulse, pulsus paradoxus, murmur, displaced apex beat, tender hepatomegaly, & lung crepitations.
Assess for underlying cause such as structural heart disease, cardiomyopathy & myocarditis.
Edema in cardiac disease often denotes a late sign in small children.
4- Protein losing enteropathy
Hx of chronic diarrhea, steatorrhea, foul stools, FTT, repeated infections & redcurrant abdominal pain.
Detailed dietary history for possible cow milk allergy and gluten hypersensitivity
Assess for complications of anemia, malnutrition and vitamin deficiency
This condition should be considered in every case of unexplained edema (even without diarrhea) especially when it is associated with hypoproteinemia.
5- Protein energy malnutrition (Kwashiorkor)
Hx of anorexia, lethargy, diarrhea, vomiting, FTT, susceptibility to infections, night blindness, inadequate or inappropriate dietary hx especially prolonged lack of protein.
In examination; growth parameters, pallor, apathy, irritability, skin changes, hair changes, & signs & symptoms of micronutrient deficiency.
6- Allergic reactions
Edema usually mild, commonly periorbital.
Hx of allergen exposure such as medications, animal dander, food preservatives and coloring.
Associated rashes such as urticarial. Assess for Steven-Johnson reaction.
Generalized edema
Circulatory overload?
No Yes
Proteinuria? Proteinuria, hematuria?
Yes No Yes No
Acute GN
Cardiac disease
Nephrotic
syndrome
Stigmata of ch. Liver
dis.?
Yes No
Chronic liver dis.
Ch. diarrhea?
Protein losing enteropathy
Investigations
A- Urine dipstick & microscopy Proteinuria, hematuria, & casts are
indicative of renal disease
B- RFT Raised serum urea & creatinine are
indicative of renal disease
C- Full blood count Normochromic Normocytic anemia
suggest chronic disease Hypochromic microcytic anemia
suggest IDA from occult GIT bleeding e.g. cow’s milk allergy
Megaloblastic anemia suggests B12 and folate deficiency from small bowel disease
D- LFT Hypoalbuminemia in the absence of
circulatory overload suggests hypoproteinemic states
Hyperbilirubinemia and elevated liver enzymes suggests liver disease
E- Chest X-ray and ECG Cardiomegaly with prominent
perihilar vascular markings/upper lobe diversion and left ventricular hypertrophy confirms intravascular fluid overload
N.B if these basic investigations do not reveal the cause of edema, further investigations may have to be done:
- Echocardiography - Serum-ascites albumin gradient
(SAAG) - CT scan or MRI abdomen
Ascitic fluid analysisSAAG > 1.1 gm/dl SAAG < 1.1gm/dl
Liver cirrhosisVeno-oclusive dis.Fulminant hepatic failureCardiac ascitesMixed ascitesLiver metastasis
Nephrotic syndromeTBNutritionalCollagen vascular dis.
High SAAG, normal protein Budd chiari synd. & constrictive pericarditis
High SAAG, low protein liver cirrhosis
Low SAAG, low protein nephrotic syndrome, TB, nutritional
Low SAAG, normal protein chylus ascites, pancreatic ascites
Management
* General measures1- Dietary management Na restriction to 2gm/m2/day Fluid restriction to 2/3 of maintenance
depending on the severity of edema2- Diuretics therapy3- Bed rest4- Specific therapy according to the cause
Points to remember
Edema more in the morning and subsiding by evening is suggestive of renal edema
Ascites to start with, followed by edema may suggest a possibility of hepatic failure
Nutritional history combined with anthropometry, vitamin & mineral deficiency signs, points to the diagnosis of nutrition deficiency states like kwashiorkor
Edema in the dependant part associated with tachypnea and abnormal findings in the heart suggests the diagnosis of cardiovascular diseases.
Thank you for your attention and patience