Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.
I'm Pradip Kamatand I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine.
Welcome to our Episode of a 19 month old female with bloody stool, petechiae and no urine output
Here's the case presented by Rahul:
A 19 month old previously healthy female was brought to the pediatric emergency department for blood in her stool. Patient was at daycare the previous day where she developed a low grade fever, congestion and URI symptoms along with non-bloody-non-bilious vomiting and diarrhea. Patient had a rapid COVID test which was negative and was sent home with instructions for oral hydration. That evening, patient began having vomiting/diarrhea which worsened. She was unable to retain anything by mouth and her parents also noted blood in her stool.
Due to this, she was rushed to the Emergency Department. In the ED here, she was hypertensive for age BP of 124/103 mm Hg, febrile, and ill. Specks of blood were noted on the diarrheal stool in the diaper.
On her physical exam she was noted to be pale with petechiae on neck and chest. Her abdomen was soft, ND, with some hyperactive bowel sounds, and no hepatosplenomegaly. The rest of her physical examination was normal.
In the ED, initial labs were significant for WBC 19, Hgb 8.8, and Platelets 34. CMP was significant for BUN of 74mg/dL and Cr of 3.5mg/dL, Na 131 mmol/L, and K of 5.5mmol/L, Ca 8.3mg/dL (corrected for albumin of 2.2g/dL), Phosphorous 8.5 AST 413, and ALT of 227, LDH > 4000. BNP was 142 and troponin negative. She was given 1 dose of CTX 50mg/kg and a 20cc/kg NS bolus. Stool PCR was sent. She was given labetalol for her hypertension, started on maintenance IV fluids and transferred to the PICU for further management.
Rahul to summarize key elements from this case, this patient has:
We have a 19-month old child with
Diarrhea and emesis X 2 days
No urine output for over 24 hours
Bloody stool
Petechiae on the neck and chest
Anemia and thrombocytopenia

All of which bring up a concern for hemolytic uremic syndrome the topic of our discussion today
Let's transition into some history and physical exam components of this case.
What are the key historical features in this child who presents with above?
Bloody stool which alludes to an invasive diarrhea
No urine output and an ill appearing state which points to a systemic inflammatory condition and end organ dysfunction.

Are there some red-flag symptoms or physical exam components which you could highlight?
Presence of petechiae which are physical exam features of thrombocytopenia
Her pallor which is a physical exam sign of anemia
Hypertension which is related to her renal dysfunction

To continue with our case, the patient's labs were consistent with:
Anemia
Thrombocytopenia
Elevated BUN and creatinine
Elevated serum LDH
The patient did not have hyperkalemia, or acidosis on initial presentation

OK to summarize, we have a 19 month old girl with:
Anemia, thrombocytopenia, and renal failure. This brings up the concern for Hemolytic uremic syndrome →

Rahul Let's start with a short multiple choice question:
A 2-year old boy is admitted to the PICU with acute respiratory failure secondary to pneumococcal pneumonia. On day # 3 of admission, the nurse reports the patient appears pale and has petechiae on his chest. The patient also has not had urine output for > 12 hours and appears to be fluid overloaded. Of the following the lab findings would be most consistent with the above clinical findings in the patient?
A) Elevation of serum haptoglobin
B) Low serum lactate dehydrogenase (LDH)
C) Negative Direct Coombs test
D) Peripheral smear showing schistocytes
The correct answer is D-Peripheral smear showing schistocytes.

Patient in the above case most likely has streptococcus pneumoniae associated hemolytic uremic syndrome commonly...