Inguinal fullness and body swelling

Edit

Inguinal fullness and body swelling

Patient name : ipomoea736146Maxima

Patient history uploaded by ArogyaUDHC social worker, Mr Kar from Mathabhanga on winter-spring 2013 (see below for the translation):

Inguinal and scrotal fullness for 6months and gradually progressive swelling of body for 6 months. Urine Albumin reported in Mathabhanga was trace and USG abdomen reported as inguinal hernia.

Global health professional network (tabula rasa) processing:

Like · · Stop Notifications · February 17 at 5:48pm

Bhavna Seth the hernia would need surgical repair. The ansarca appears more difficult to decipher- tubercular etiology could be ruled out due to the lymphocytic predominance. The man also has pus cells in his urine for which an antibiotic course could be started.
February 17 at 6:12pm · Like
Tamoghna Biswas Why was an USG advised to diagnose inguinal hernia?
February 17 at 6:26pm · Unlike · 2
Bhavna Seth ^ point! Tamoghna Biswas
February 17 at 6:52pm · Unlike · 1
Bhavna Seth They possibly just did the USG as a part of the anasarca work up & mentioned the findings present Tamoghna Biswas
February 17 at 7:37pm · Like
Rakesh Biswas Yes this patient got his USG done from Mathabhanga and posted it to us along with the urine report before arriving here at Bhopal and when we examined him here we found inguinal fullness and scrotal edema but no hernia in the inguinal canal and no impu...See More
February 17 at 8:03pm · Like
Bhavna Seth in the ascitic/pleural tap, may do ADA levels if feasible to rule out TB(tricky to explain the left side predominance), ALP levels in these may also be done to rule out pancreatitis(though how to explain so much fluid). nephrotic is ruled out. no cells?
February 17 at 8:44pm · Like
Kaustav Bera We can probably do a culture sensitivity of the fluid to rule out infections also I guess, since malignant cells are not present.
February 17 at 8:46pm · Like
Tamoghna Biswas Where is the report of the diagnostic tap? I can't find it in the images. Summarily is it a transudate or an exudate?
February 17 at 8:49pm · Like
Kaustav Bera In the narative. Pleural fluid protein 0.34g/L and TLC 50 cells with 60% lymphocytes. Ascitic fluid SAAG 0.1 and TLC 50 cells.

Copied.
February 17 at 8:50pm · Unlike · 1
Bhavna Seth its low SAAG, concept of transudate-exudate doesnt always apply with SAAG. in pleural tap- can't be sure
February 17 at 8:53pm · Like · 1
Tamoghna Biswas Umm, Bhavna SAAG correlates more with portal Htn, agreed, but a low SAAG generally points to exudate.
February 17 at 8:56pm · Like
Bhavna Seth true that Tamoghna, though it is more of a measure of the starling forces in action. not necessarily exudate exclusively I suppose- as nephrotic syndrome, biliary leak, serositis, vasculitis also have low saag, we were taught not to confuse the 2 concepts saag vs transudate/exudate. Though yes- pleural tap mein will still aren't sure if its transudate/ exudate- appears to be exudate with the more cells
February 17 at 9:03pm · Unlike · 1
Tamoghna Biswas With a past history of jaundice, we can expect he has already been through USG whole abdomen?
February 17 at 9:09pm · Like
Rakesh Biswas Excellent response Bhavna. Yes Tamoghna the ascitic and pleural tap results are provided in the narrative as the scanned images are only for the patients and social workers to send from Mathabhanga and the tap was done here in Bhopal. Yes the U...See More
February 17 at 9:13pm · Like · 1
Rakesh Biswas The ADA was around 15 from both the pleural and ascitic fluids.
February 17 at 9:14pm · Like
Tamoghna Biswas What were the urine reports from PCMS?
February 17 at 9:18pm · Like

People's Hospital, Bhopal Notes on Feb 15 2013

On examination anasarca, no facial puffiness and left sided pleural effusion. This patient got his USG done from Mathabhanga and posted it to us along with the urine report before arriving here at Bhopal and when we examined him here we found inguinal fullness and scrotal edema but no hernia in the inguinal canal and no impulse on coughing.
He also had a large left sided pleural effusion and ascites which were subjected to a diagnostic tap and the results are:.Pleural fluid protein 0.34g/L and TLC 50 cells with 60% lymphocytes. Ascitic fluid SAAG 0.1 and TLC 50 cells.

The patient's friend who had accompanied the patient told us that he was a frequent consumer of alcohol (country liquor aka bangla) and we kept a provisional diagnosis of alcoholic cirrhosis. His Ram's horn penis was drained of the fluid and restored to shape by our surgeon.

His urine RM came in the evening showing 4+ albumin and 8-10 dysmorphic RBCs along with urine protein creatinine ratio to the tune of 10. He was a frank nephrotic syndrome with active sediment. His blood pressure was 140/90. He was advised a renal biopsy but couldn't afford it.

Global health professional network (tabula rasa) processing 2:

Kaustav Bera I came across a case of Nephrotic syndrome secondarily to SLE in the Medicine OPD. The treatment suggested was Prednisolone and Cyclophosphamide. The patient had come for a follow up and was apparently well, except complaining of pain in the hand.
February 17 at 10:53pm · Like
Rakesh Biswas Yes there is more evidence for treatment of secondary nephrotic syndrome in adults though unfortunately minimal for primary nephrotic syndrome as we may suspect in this patient. What would you do to prognosticate this patient before you think of specific treatment. His creatinine and urea were absolutely well within normal limits.
February 17 at 11:02pm · Like
Kaustav Bera A renal biopsy since the nephrotic syndrome is probably not secondary to any known etiology, to determine which of the pathological variants of nephrotic syndrome the patient has.

The normal creatinine points towards no complications?...See More
February 17 at 11:13pm · Unlike · 2
Rakesh Biswas Yes the dysmorphic RBCs are suggestive of glomerular origin and this active sediment can be seen in certain primary types such as MPGN, FSGS etc
February 17 at 11:22pm · Like · 1
Rakesh Biswas The patient wasn't able to undergo a renal biopsy. Assuming that it is minimal change (supposedly the most common primary glomerulonephritis in India) would you go ahead with steroids? Can we search the evidence for beneficial effect of steroids in Adult minimal change disease? Kaustav, Aakriti, Bhavna, Subhankar, Tamoghna, Parijat
March 1 at 7:54pm · Like
Kaustav Bera http://onlinelibrary.wiley.com/.../14651858.../abstract

Cochrane has a review (2009) which is pretty inconclusive with data lacking in adults where minimal change disease is a rarity. This is the conclusion they reached where they d...See More
Interventions for minimal change disease in adults with nephrotic syndrome - The Cochrane Library -.
onlinelibrary.wiley.com
Palmer SC, Nand K, Strippoli GFM. Interventions for minimal change disease in ad...See More
March 1 at 8:01pm · Like · 1 · Remove Preview
Parijat Sen The question I believe Rakesh Biswas sir is whether we proceed with a trial therapy of sterois or try and evaluate for secondary causes??...such as an occult malignancy, or a chronic infection (HBV HCV)...Drug history seems unlikely as a cause....
March 1 at 8:57pm · Like
Kaustav Bera Parijat da - Wasn't most secondary causes ruled out? And I have a question isn't minimal change disease rare in adults but is it still the most common presentation of nephrotic syndrome in India?
March 1 at 9:18pm · Unlike · 2
Parijat Sen Kaustav Sorry I hadnt been following the discussion from the ebginning so just tried to egt a bird's eye view .... Well it's quite common in India and yes more rpevalent in kids but even ina dults there's a steorid sensitive form of Nephrotic SYndrome (name I forgot) so a trial may not be a bad idea
March 1 at 9:19pm · Unlike · 2
Rakesh Biswas To answer Kaustav's question about the rarity or commonality of minimal changes there are a few hospital based studies: http://www.ncbi.nlm.nih.gov/pubmed/11273537, http://qjmed.oxfordjournals.org/content/64/3/729.abstract which mention minimal change ...See More
Spectrum of renal diseases in India... [J Assoc Physicians India. 2000] - PubMed - NCBI
www.ncbi.nlm.nih.gov
PubMed comprises more than 22 million citations for biomedical literature from M...See More
March 1 at 9:41pm · Like · 1 · Remove Preview
Aakriti Pandita I thought membranous glomerulonephritis is most common cause of glomerulonephritis in adults, don't know about Indian set up though. But in this case, all secondary causes are not ruled out as RA,myxedema, sarcoidosis,etc . As far as TB is concerned, I...See More
March 1 at 11:08pm · Like
Kaustav Bera Aakriti Pandita - Why is it an exudative effusion?
March 1 at 11:11pm · Like
Aakriti Pandita Well, from the values it looks like that, though serum protien value could make it clearer..even then we can never say 100% even with light's criteria in hand. 25% of transudates are misclassified as exudates. So, better is to get a gradient, between serum and pleural fluid protien levels.
March 1 at 11:16pm · Like · 1
Kaustav Bera And in any case most secondaries have been ruled out.
March 1 at 11:17pm · Like
Aakriti Pandita what apart from cardiac, liver and nephrotic causes ? was lymphadenopathy ruled out?
March 1 at 11:18pm · Like
Rakesh Biswas Aakriti some of his key diagnostic findings are buried in the thread. His urine RM which came later in the evening showed 4+ albumin and 8-10 dysmorphic RBCs along with urine protein creatinine ratio to the tune of 10. He was a frank nephrotic syndrome...See More
March 2 at 8:40pm · Like
Rakesh Biswas No apparent secondary cause of nephrotic syndrome in this patient.
March 2 at 9:15pm · Like
Aakriti Pandita Ohh, I didn't see that report. Well, in this case yes, steroids should be started preferably with ACEI/ARB's. If still no improvement, then immunosuppressants can be added. If patient has not progressed to FSGS, then he should be responsive to above treatment.
March 2 at 9:42pm · Like
Rakesh Biswas As discussed in the above threads there is grade C evidence for this which is low and indicates that the true effect may be substantially different from the estimate of the effect. Would you still recommend steroids?
March 2 at 10:16pm · Like
Rakesh Biswas Parijat Sen, Manu Mathew, Kaustav Bera
March 2 at 10:17pm · Like
Rakesh Biswas The international Society of Nephrology used the GRADE system to rate the strength of evidence and the strength of recommendations where grade 1 means recommended and gr 2 means suggested. They graded the above situation (assumed minimal change nephrotic syndrome) as Gr1C for treatment with steroids.http://www.kdigo.org/clinical.../pdf/KDIGO-GN-Guideline.pdf Manu, Shivika comments?
March 2 at 10:39pm · Like
Aakriti Pandita yes I still would because 1) we dont know what type of primary glomerulonephritis it is 2) It's a grade C evidence 3) Response from each patient differs 4) Steroids won't harm, but will provide an empirical evidence of what patient might have 5) There is no other option.
March 2 at 11:08pm · Like
Aakriti Pandita some textbooks write minimal change disease shows good response in adults as well, though response is gradual than in children, and if there is relapse, remission occurs ultimately. (if we suppose t...See More
Textbook of Nephrology for the Asian Pacific Physicians
books.google.co.in
The revised volume has included almost all the common disorders found in clinica...See More
March 2 at 11:20pm · Unlike · 2 · Remove Preview
Rakesh Biswas Thank Aakriti for posting this text book experience which i guess is the author's alone as this particular text book chapter seems to lack references (unlike the other chapters in the same text book link you provided). Perhaps the EBM movement evolved ...See More
March 3 at 1:29pm · Like · 1
Rakesh Biswas Aakriti your point 5 is perhaps the most important point in deciding for this patient.
March 3 at 1:38pm · Like · 1
Aakriti Pandita Out of curiosity, I would like to know is there any other definate evidence(study) that claims steroid administration is not a good idea in MCD in adults. Even Harrison mentions that 80-85% people attain complete remission but only after a longer course of 20-24 weeks.
March 3 at 1:42pm · Unlike · 1
Manu Mathew Hi,
Use of steroids is given a 1c meaning- Strong recommendation, low evidence.
In plain English the guideline panel is saying to the decision maker, we think that you should use steroids despite the fact that there is no solid proof. Aakriti has clearly enumerated the probable reasons behind such a recommendation.

Both the thread and document are very long to read. Sorry, I just scanned through both of them..
Ideally, they should not have used numbers or letters to represent GRADE(this being the advantage of it). They should also have displayed some sort of quantitative benefit (relative risks and absolute risks) and the reasons for their judgement in a GRADE SOF Table, so that we dont need to imagine what they had thought.
March 3 at 2:48pm · Unlike · 2
Rakesh Biswas Thanks Manu, Yes it would have been nice if the guideline developers had been more explicit. Aakriti we would need a good blinded RCT to answer that very good question about what are the harms of initiating steroid or adjunctive immunosuppresive therapy even if the evidence is grade C. If we had a good blinded RCT the evidence would not remain grade C though.

Follow up history from Mathabhanga on 27/02/13

After the visit to People's College of Medical Sciences hospital, the fluid in my abdomen is no longer there and the swelling all over is almost gone. However presently I am having problem of severe irritation in my throat. Abdominal distension due to gas, which does not get better even on taking Omez D.

New Investigation Reports attached.

Follow up on 16/03/13

Patient still complains of abdominal pain, constipation, headache and also sever throat irritation. The prescribed medications have been all taken over their due course.

Follow up on April 2013

Patient is a day laborer and has begun his regular occupational activities in full swing and is reportedly asymptomatic and has been advised repeat Urine for estimation of current status of proteinuria and glomerular injury by our social worker Mr Kar on telephone.

Winter December 2013 update:

The patient maintains good health despite not being on any treatment. We have asked our health worker to get his urine for protein tested but the patient has been declining (presumably due to the fact that he feels better and doesn't want to bother about it further).

Similar health cases from BMJ