A one year old boy is brought to his pediatrician by his mother who has noted colicky adominal pain and fever.

On examination his scrotal skin is erythematous and warm and he has a urethral discharge. Investigation reveals

a leukocytosis and pyuria. Sedimentation of the urine revealed E. coli which is successfully treated with

antibiotics by his pediatrician. When next seen at the clinic the next week he is symptom-free

The most appropriate next step would be

a) complete urologic investigation

b) no further treatment or investigation is necessary

c) radionuclide scintigraphy

d) inguinal-scrotal ultrasound

e) ceftriaxone and doxycycline

Correct answer: A

EXPLANATION

The occurrence of epididymitis in infants suggests the presence of urinary infection and the likelihood of an

associated structural genitourinary abnormality, requiring complete urologic investigation. All pediatric cases of

epididymitis require immediate consultation due to the high incidence of associated genitourinary anomalies.

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Question . 1. Erythema nodosum, an erythematous, nodular, often pretibial

rash, is associated with all of the following except:

Inflammatory bowel disease

Pseudotumor cerebri

Explanation: Erythema nodosum in itself is not a disease

but is associated with many infections (e.g., group A

streptococcal infection, tuberculosis, Yersinia infection,

histoplasmosis, coccidioidomycosis) and inflammatory

states (e.g., inflammatory bowel disease, systemic lupus

erythematosus, juvenile rheumatoid arthritis, sarcoidosis)

and may occur after administration of drugs (e.g.,

sulfonamides, phenytoin, oral contraceptives). (See

Chapter 143 in Nelson Textbook of Pediatrics, 17th ed.)

Sarcoidosis

Yer sinia

 Birth controlpills

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A 14-year-old female presents with a two week history of deteriorating puffiness of the face.

She has been aware of tiredness and lethargy over the last two months since having acquired

a throat infection. Over this period she has gained at least 5 kg in weight over this time. She

had a similar throat infection aged 10 from which she made an uneventful recovery. There is

nothing else of note in the history and she takes no medication. Examination reveals

generalised puffiness with pitting oedema of the lower limbs. Her blood pressure is 133/86

mmHg with a pulse of 88 bpm. Chest, cardiovascular and abdominal examinations are normal.

Her urine dip stick produces +++ protein.

Other investigations reveal:

Haemoglobin 14.6g/dl

White cell count 6 x 109/l

Platelets 250 x 109/l

Sodium 136 mmol/l

Potassium 4.0 mmol/l

Chloride 103 mmol/l

Bicarbonate 24 mmol/l

Urea 4.2 mmol/l

Creatinine 93 micromol/l

Serum albumin 25 g/l

24 hour urine protein 4.3 g/l

Which is the best treatment for this patient?

Available marks are shown in brackets

1 ) Observe [0]

2 ) Salt poor albumin [0]

3 ) Intravenous frusemide [0]

4 ) High dose corticosteroids [100]

5 ) Cyclophosphamide [0]

Comments:

This patient has the nephrotic syndrome as defined by a triad of hypoalbuminaemia,

proteinuria > 3g/24hrs and oedema. The commonest cause of nephrotic syndrome in a child is

minimal change disease, which usually responds to a course of high dose corticosteroids.

Cyclophosphamide may hasten a remission, but given its cytotoxic profile, should be reserved

for steroid-resistant cases. If possible it should be avoided in childhood. Salt poor albumin and

iv frusemide may be useful adjuncts for managing oedema, but is not curative of proteinuria. If

the nephrotic syndrome is left unchecked, complications include Streptococcal sepsis, venous

thromboembolism and hypercholesterolaemia

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