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: Dark brown urine in a profoundly swollen 6-year old child
Clinical History:ย  A 6-year old boy had a throat infection that improved on its own without treatment. Two weeks after, the mother noticed that the child was somnolent and appeared sick, even though he did not have a fever. He refused to eat and did not want to go to school. The mother also noticed that his face was swollen. The urine was dark brown and the amount of urine seemed to be less then normal. Otherwise the child was healthy.
Physical Findings:ย  The child appears well developed and is mobile. His movements are sluggish, and he is a bit subdued. No localizing symptoms were recorded, and he has no pain in the throat or anywhere else. He appears to have periorbital edema and his lips seem to be swollen. His fingers and toes are also swollen. He is also slightly short of breath. His pulse rate is 90 beats/minute, and the blood pressure is 145/95 mm Hg.
Laboratory Findings: At the time of admission the serum WBC and RBC counts were within normal limits. Serum showed slight elevation of BUN and creatinine, with a normal BUN:CR ration of 10:1. Serum electrolytes were within normal limits. Albumin was slightly lower than normal.
Urine was positive for 3+ protein and for3+ blood by dipstick. The examination of urinary sediment revealed numerous RBCs, many of which were dismorphic. Red blood cell casts were also present. Urine culture was negative.
Follow-up laboratory testing revealed oliguria, proteinuria in the rang of 1.5 g protein/24 hours, persistent hematuria, and RBC casts in the urine.
Outcome: The child was treated symptomatically and recovered completely.
Questions and topics for discussion:

  1. What is the most likely cause of a throat infection in a 6-year old child? Does he require treatment?
  2. What is the significance of facial swelling? List the possible causes of facial swelling?
  3. What are the possible causes of dark urine?
  4. Please interpret these physical findings. What is the cause of hypertension?
  5. Please interpret these laboratory findings. Does this child have renal failure?
  6. What is the cause of hypoalbuminemia? Which clinical finding could be attributed to hypoalbumonemia?
  7. What is the cause of proteinuria and hematuria? How could one quantify better the dipstick data?
  8. What is the significance of dismorphic RBCs and RBC casts in the urine sediment?
  9. Do all patients with this disease recover completely?


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