Critical Cases - Swollen 2 year old!


  • 2 yo female p/w "whole body swelling"
  • Seen previously at urgent care and diagnosed with an allergic reaction, rx for diphenhydramine and prednisone which she has been taking 
  • No fever, no trouble swallowing or breathing, no wheezing, and no rash
  • No new exposures (such as chemicals or pets) 

Physical Exam

VS: Pulse 122, BP: 120/88, Temp 98.6F rectally, RR: 30, Wt. 15kg, SpO2 100% 


HEENT: Notable facial swelling with periorbital edema, without erythema, conjunctiva clear 

Oropharynx: Clear, no stridor, no cervical lymphadenopathy

Lungs: clear, no wheezing, no crackles 

Abd:  Distended abdomen, no fluid wave

GU: Labia swollen

Extrem: All 4 extremities + notable non-pitting edema without tenderness, no warmth, erythema, bruising, or rashes. Strong pulses. 




  • Nephrotic syndrome vs other acute renal failure most likely 
  • Cardiomyopathy such as myocarditis or other cause of CHF, although less likely given clear lungs, no significant tachycardia, no dyspnea, no prior infectious symptoms.
  • Less likely cirrhosis, no risk factors for this, no bruising, no jaundice, no encephalopathy 



Lab results:


  • UA showed 4+ protein 
  • Creatinine 0.25 
  • Albumin: 1.1 (low)
  • Protein: 3.4  (low)


  • Results consistent with nephrotic syndrome


Management and Case Conclusion:


  • Pediatric nephrologist recommended 10g of 25% albumin over 3 hours followed by IV Lasix and transfer to a pediatric specialty hospital for further management
  • The patient was a admitted for 4 days and treated with IV solumedrol, diuresis with Lasix, and infusions.
  • On discharge she had lost 2kg and -4 liters of fluid. 
  • The patient had multiple follow up visit with a nephrologist, her swelling had resolved, her BP improved to normal range
  • Pt continued to still have proteinuria despite a prolonged course of high dose steroids
  • 2 months later, she was noted to have swelling again of her face and abdomen, so she was readmitted for a renal biopsy and genetic testing (results pending), as she seems to have steroid-resistant nephrotic syndrome. 



Nephrotic syndrome is diagnosed by the following 4 criteria: 

1.    Proteinuria (cut offs are generally >3-4g in 24 hours or protein: creatinine ratio >300-350mg/mmol) 

2.    Hypoalbuminemia (<2.5-3g/dL) 

3.    Hyperlipidemia (often >350mg/dL) 

4.    Peripheral edema.  


  • Many patients also have hypertension, but this is not necessary to make the diagnosis. 
  • Remember on average, a normal systolic BP in a child is 90mmHg + (2 x age in years), this pt had systolic of 124 (expected 94)
  • There are many causes of primary nephrotic syndrome, such as: focal segmental glomerulosclerosis, membranous nephropathy, and minimal change disease. 
  • Minimal change disease is the most common nephrotic syndrome in children and accounts for 70-90% of nephrotic syndromes in children <10 years old. 
  • The gold standard for diagnosis is a renal biopsy, however this is not usually necessary with first presentation of nephrotic syndrome