224. What are causes of hypertension in nephro-tic syndrome?
Ans. Hypertension is not a feature of nephrotic syndrome, but may be seen in diseases that cause nephrotic syndrome such as;
• Diabetic nephropathy
• SLE and polyarteritis nodosa
• Nephrotic syndrome complicated by CRF
• Focal glomerulosclerosis is commonly associated with hypertension.
225. What is indication of renal biopsy in nephrotic syndrome?
Ans. The renal biopsy is done for following reasons:
• To confirm the diagnosis
• To know the underlying pathological lesion
• To plan future treatment
• To predict the prognosis and response to treatment.
226. What is the common pathological lesion in diabetic nephropathy?
Ans. Kimmelstiel-Wilson syndrome (diabetic nodular glomerulosclerosis) is the common pathological lesion.
• It occurs commonly in type I diabetes than type 2 diabetes
• Usually develops as a long-term microvascular complication of diabetes (duration of diabetes >10 years)
• Common presentation is moderate to massive proteinuria. Hypertension may develop later on.
• With the onset of this lesion, the requirement of insulin falls due to excretion of insulin antibodies in urine.
• Progresses to end-stage renal disease (ESRD) over a period of few years.
• The characteristic histological lesion is nodular glomerulosclerosis.
227. How does nephrotic syndrome differ from nephritic syndrome?
Ans. The differences are tabulated (Table 1.63)
Table 1.63: Differences between nephrotic and nephritic syndrome
Feature Nephrotic Nephritic
syndrome syndrome
Onset Slow, insidious Sudden, acute chronic disorder renal disorder Proteinuria Massive > 3.5 g/d Moderate 1-2 g/d Hyperlipidaemia Present Absent
and lipiduria with faulty casts
Hypertension Not a feature An important feature
Volume of Normal Oliguria
urine passed in 24 hr
Haematuria Not common A common and
integral component of syndrome
Acute renal Uncommon Common
failure
Relapse and Commom Uncommon
remission
Course Chronic 70-80% cases
progressive recover completely disorder while others pass on
to RPGN
CASE 19: ANAEMIA
Figs 1.19A and B: A. A patient with severe anaemia. B. Clinical features of anaemia
Clinical Presentations
• Patients with mild anaemia are asymp-tomatic. Anaemia is discovered on routine haemoglobin estimation done for some other purposes. On sympto-matic enquiry, they may admit history of occasional exertional dyspnoea, palpitations and fatigue.
• Patients with severe anaemia usually complain of weakness, weight loss, dyspnoea, palpitation, throbbing head-ache, dizziness, tinnitis and menstrual irregularity in females, tingling in extremities and GI symptoms (nausea, anorexia).
• Anaemia may be a presenting feature of certain chronic disorders, e.g. mal-absorption, chronic renal failure, chronic blood loss (haematemesis, malaena, menorrhagia) or malignant disorders.
Note Anaemia is a sign not a complete diagnosis, hence, cause of anaemia must be mentioned in the diagnosis e.g.
malabsorption with anaemia, CRF with anaemia etc.
A 19 years female (Fig. 1.19A) presented with pallor, fatigue, malaise, weakness and breathelessness on exertion. There was no history of fever, loose motion, blood loss, any surgery. No history of drug intake. She has generalised pallor with slight puffiness of face.
Points to be noted in History
• Symptoms and their analysis
• History of fever, blood loss, drug intake loose motion, jaundice, dysphagia, vomiting
• Menstrual history, history of recent delivery and blood loss if any
• History of piles or repeated haemate-mesis
• Nutritional history
• Past history of tuberculosis, bleeding, any surgery, trauma, repeated abortions/deliveries
• Personal history, e.g. alcoholism
• Family history of jaundice.
General Physical Signs
• Facial apprearance or look
• Puffiness of face or periorbital oedema
• Look for anaemia at different sites, koilonychia, platynychia, bleeding from gums or nose
• Neck examination for JVP, lymphnodes and thyroid
Systemic Examinations I. Examination of CVS
Inspection
• Look for apex beat, e.g.
location, type
• Any chest deformity
• Chest movements Palpation
• Trachea—Note any deviation
• Apex beat—confirm the findings of inspection
• Chest movements and expansion
Percussion
• Heart borders, cardiac and liver dullness
• Lung resonance Auscultation
• Heart, e.g. sounds, mur-murs, if any murmur, note its various characteristics
• Lung sounds, e.g. breath sounds, crackles and rales II. Examination of abdomen
Inspection
• Contour, shape of umbilicus, hernial sites, any swelling or mass or distension
Palpation
• Palpate for any mass The patient has pale tongue, conjunctival
along with puffiness of face
• Pulse, BP, temp, respiration
• Skin for any bleeding spots or rash
• Oedema feet
• Look for deficiency signs of hypo-proteinaemia, e.g. flabby muscles, wasting, thin skin.
• Palpate for liver, spleen and kidneys
• Elicit any tenderness Percussion
• Percussion note. Note over the mass if present. Define upper border of the liver Auscultation
Hear for sound, bruit or rub III. Examination of CNS
• Look for signs of neuropathy IV. Endocrine system
• Look for signs of hyper or hypothyroidism.
228. What is the clinical diagnosis of the patient in picture?
Ans. The young patient presented with exertional breathlessness, fatigue and malaise. She was found to have generalised pallor and paleness of mucous membrane. The clinical diagnosis is anaemia the cause of which is nutritional.
229. How do you define anaemia?
Ans. A hemoglobin level < 11.0% g in an adult female and < 12.0 g% in an adult male is taken as anaemia.
230. What are symptoms and signs of anaemia?
Ans. For symptoms – read clinical presentations. For sign – see Figure 1.19B.
231. What are the causes of anaemia?
Ans. The common clinical causes of anaemia in India are:
• Nutritional, e.g. deficient intake of iron, folate and protein in diet
• Hookworm infestation
• Chronic blood loss, e.g. piles, haematemesis, menorrhagia, malaena etc.
• Chronic diarrhoea and malabsorption.
• Pregnancy associated anaemia
• Hypoproteinaemia, e.g. nephrotic syndrome, cirrhosis liver
• Haemolytic anaemia, e.g. malarial parasite or drug-induced in G6PD deficiency.
• Anaemia of chronic infection, e.g. tuberculosis, SLE, rheumatoid arthritis.
• Anaemia associated with malignancies, e.g. leukaemia, lymphoma, carcinoma stomach, colon etc.
• Hereditary anaemia.
232. What are common causes of iron deficiency anaemia (microcytic hypochromic)?
Ans. Common causes are as follows:
1. Nutritional deficiency, e.g. inadequate iron intake 2. Increased demands, e.g. pregnancy and lactation 3. Blood loss
• GI loss, e.g. bleeding peptic ulcer, piles, haemate-mesis, hookworm disease
• Uterine, e.g. menorrhagia, repeated abortions, dysfunctional uterine bleeding
• Renal – haematuria
• Nose – epistaxis
• Lung – haemoptysis
4. Malabsorption due to any cause.
233. What are clinical signs of iron deficiency anaemia?
Ans. Clinical signs are:
• Pallor
• Glossitis, angular stomatitis, cheilosis
• Koilonychia
• Dysphagia (Plummer – Vinson syndrome)
• Mild splenomegaly
• History of pica (eating of strange items, e.g. coal, earth).
234. What is sideroblastic anaemia (nonutili-sation of iron)? What are its causes?
Ans. A red cell containing iron is called siderocyte. A developing erythroblast with one or two iron granules is called sideroblast. Iron granules free in cytoplasm of RBCs are normal, but when they form a ring round the nucleus in red cells, then they are considered abnormal and called ring sideroblasts. The anaemia in which ring sideroblasts
are present is called sideroblastic anaemia. It is due to nonutilisation of the iron in the bone marrow resulting in accumulation of iron as granules in developing red cells. Sideroblastic anaemia may be primary (hereditary or congenital) or secondary (acquired). The causes are:
1. Hereditary (congenital) 2. Acquired
• Inflammatory conditions
• Malignancies
• Megaloblastic anaemias
• Hypothyroidism
• Drug induced
• Lead poisoning
• Pyridoxine deficiency.
235. What are causes of megaloblastic anaemia?
Ans. It occurs due either to folate or Vit. B12 deficiency or both. The causes are:
1. Nutritional, e.g. inadequate intake, alcoholism.
2. Increased demands of folic acid, e.g. pregnancy, lactation.
3. Following haemolysis 4. Malabsorption syndrome;
• Ileal disease
• Gastrectomy
• Blind – loop syndrome
5. Drug induced, e.g. anticonvulsants, methotrexate, oral contraceptive, pyrimethamine.
6. Parasitic infestation, e.g. Diphylobothrium latum.
236. What are causes of haemolytic anaemia?
Ans. (Read haemolytic jaundice).
237. What are causes of aplastic anaemia?
Ans. Followings are the causes: