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A 13 year old female student from suryapet came to the OPD with chief complaints of

Vomitings on Monday night at 10 pm

breathlessness since 1 day

History of present illness:

Patient was apparently asymptomatic before 2020 that is till the age of 11 years,then she noticed swellings in the neck bilaterally,no pain, firm in consistency.

She also had fever which was insidious in onset , intermittent, no night rise of temperature, relieved with medication dolo 3 tid

She also had Non productive cough , no hemoptysis ,relieved with medication.
These symptoms was continued for 2-3 months.

After consulting rmp they started att as her mother has tuberculosis.
Eventually swellings size decreased and symptoms got relieved.

But the fever was not subsiding,so they stopped taking medication.

As rmp suggested , they went to hospital in Hyderabad and got her tested for tuberculosis:
-fnac
-cancer tests
- tb tests
-mantoux
-sputum culture
-cbnaat
because her mother is a known case of tuberculosis.

She got admitted for 10 days and recieved symptomatic treatment

She also had complaints of joint pains wrist and knee.

They suspected it to be automimmune and started her on Hcq and wysolone tab which they used for 15 days.
After that they tested for

ANA ELISA equivocal

ANA IFA negative

ANTI DS DNA ELISA positive

ANTI DS DNA IFA negative

So she went back home

2021

In June she started developing pigmentation/rash over face which then was seen on scalp evident because of hair loss and on trunk since 3 months,not associated with itching.

pedal edema which was upto ankles and progressed till knee in the last 3 months,pitting type.

Then she was taken to area hospital and got tested and the attender(father) was informed that she has tuberculosis.

2022

Ln biopsy was done in May

Mycobacterial gene expert test was done

No reports available

So they started her on ATT and recieved regular treatment for 6months.

2023

Her symptoms settled and she was fine until January 10 when she develop generalized edema.

They went to another hospital and got tested and was told to have proteinuria.

In January and February she had mild fever.

1 week back she developed fever and edema again.

On 13 March that is Monday night 10 pm she had episodes of vomiting 4 episodes ,food as contents,non bilious.

She also developed grade 2 sob and so they got her to here at 5.30am.

In 5th class her weight was 28kgs then in 6th class 23kgs,8th class 21 kgs

After att treatment her weight got improved to 23kgs that is last year

In December 26kgs, 24kgs ,yesterday it was 25kgs.

Past history

K/c/o tuberculosis

Not a known case of diabetes, hypertension, epilepsy, thyroid

Treatment history :

Used ATT for 6 months for TB

Personal history :

Single

Student

Daily routine:

She studied in local school until 4th class.

In 5th class she went to gurukul school and joined in hostel and was fine until 6th class.

In hostel

5 am wake up

Gets ready by 6 am

6:30 am to the ground for yoga,exercises

7 am ragi Java

7.30 am prayer

8am classes

9.15 am breakfast

Classes until 1.30

1.30 to 2.30 lunch

2.30 to 4.30 study hour

4.30 to 5 snacks

5.00 to 6 pm walking ,playing

6 to 6.30 prayer

7 pm dinner

Till 9 pm study hour

9pm sleep

In 7th class she started developing symptoms.

After 7th she stopped going to school as it got worse and she was frequently visiting hospitals.

She went to hostel again after her att treatment and subsidence of symptoms in dec.

Was fine until January and she came back home again .

At home :

6am wake up

7 am tea

Breakfast and fruits

Tablets

Sleeps until afternoon

2.30 to 3 lunch

2 months after taking ATT her appetite was increased and she ate more food, frequently- 5times a day

5pm Walking exercises

Eve 6pm fruits

Songs prayers

8pm dinner

9pm sleep

Personal history:

Diet mixed

Appetite normal

bladder movements oliguria
bowel normal

Sleep decreased

Addictions none

Family history

Mother was diagnosed with TB in 2014 and used ATT irregularly.

Symptoms got worse in 2022 and she died in sept 2022

Birth history:

1st born child

Born in 2010

2nd degree consanguineous marriage

Lscs

Father has no idea about immunisation status

Menstrual history

Not attained menarche yet

General examination:

Patient is conscious coherent and cooperative

Well oriented to time place. And person

Patient examined in well lit room

Pallor present

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Edema present

Vitals

On 14/3/23

Bp 130/80mmhg

Pulse rate 110 bpm,regular, normal volume

Respiratory rate 32 cpm

Sp02 99%

On 15/3/23

Bp 130/90 mm hg

Respiratory rate 26cpm

Pulse rate 120bpm

Temperature afebrile

Sp02 98%

On 17/3/23

BP: 130/100 mmhg

PR: 88bpm

RR: 24cpm

TEMP: 97.8

GRBS: 168 mg/dl

systemic examination:

Abdominal examination

Shape - slightly distention.

Umbilicus - Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.

Palpation

soft, tenderness in right and left Hypochondrium, epigastrium.

Percussion

Fluid thrill and shifting dullness present

Auscultation

Bowel sounds heard

No bruit or venous hum.

Respiratory examination

Bilateral air entry present

Dull note

Vocal resonance decreased

Cvs examination

S1 s2 heard, no murmurs

CNS examination

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal sensations

Motor examination normal

Reflexes normal

Investigations

Spot urine sodium 166mmol/l

Spot urinary potassium 20.5

Abg

pH 7.4

Pc02 14.9 mm hg

P02 79.8mm hg

Hc03 9.2 mmol/l

O2 saturation 96%

Serum electrolytes on 14\3

Sodium 136 meq/l

Potassium 4.4 mEq/l

Chloride 106 meq/l

Serum creatinine 0.6mg/dl

Esr 70 mm

CRP neagtive

Blood urea 29 mg\dl

FBS 100 mg\dl

Blood group 0+

Rheumatoid factor negative

HIV non reactive

Hbs ag non reactive

Urine examination:

Colour pale yellow

Appearance clear

Acidic

Specific gravity 1.010

Albumin ++

No sugar, bile salts, bile pigments, rbc, crystals, casts, amorphous deposits

Pus cells 3 to4 \hpf

Epithelial cells 2 to 3 \hpf

On usg

Liver,gallbladder,pancreas,spleen, uterus,ovaries normal

Moderate ascites

Bilateral pleural effusion

Moderate pericardial effusion

Bilateral grade 2 rpd change

Hb 7.5 g\dl

WBC 4200 cells\cumm

Neutrophils 60

Lymphocytes 36

Eosinophils 02

Monocytes 02

Basophils 0

Pcv 24.6 vol%

Mch 76.4 fl

Mchc 30.5%

Rdw 20.6 %

Rbc count 3.2 million\cumm

Platelet 1.57 laksh\cumm

Smear normocytic normochromic anemia

On 15\3

Serum creatinine 1.0 mg\dl

Sodium 1.37 meq\l

Potassium 4.7

Chloride 104

Spot urine protein 393 mg\dl

Spot urine creat 37.8 mg\dl

Ratio 10.3

Clinical images