Objectives:

• Evaluate and manage a child with hypovolemia and renal failure
• Construct a differential diagnosis for renal failure in a child
• Recognize a clinical history and laboratory findings suggestive of hemolytic uremic syndrome
• Identify causes of hemolytic uremic syndrome

The parents of a 2-year-old female bring her in to your office for a weeklong history of diarrhea. Initially, her stools were loose and watery, but over the last few days, they have become bloody. The patient has appeared to have abdominal pain on occasion, and her appetite is depressed. Despite bloody diarrhea, her parents attempted to care for her at home until she became more lethargic. They are also worried about some bruising on her extremities.

The nurse takes her vital signs: temperature 37.2° C, pulse 145, blood pressure 88/47, and respiratory rate 40. The patient appears pale, with slight scleral icterus. You note petechiae and purpura on the extremities. Her abdomen is diffusely tender. She responds to commands but appears very lethargic.

While you are arranging her admission to the hospital, some laboratory tests return: Hgb 8 g/dL, Hct 24%, WBC 14,000/mm³, platelets 50,000/ mm³, Na 128 meq/L, K 3.9 meq/L, HCO₃ 14 meq/L, BUN 38 mg/dL, creatinine 2.1 mg/dL. The peripheral blood smear shows schistocytes, burr cells, and grossly reduced number of platelets.

1		Which of the following is the most appropriate INITIAL management of this patient?
			A)	Intravenous fluids.
			B)	Dialysis.
			C)	Platelet transfusion.
			D)	Corticosteroids.
			E)	Antibiotics.
2		Based on the available information, which of the following is the most likely diagnosis?
			A)	Thrombotic thrombocytopenic purpura.
			B)	Hemolytic uremic syndrome.
			C)	Postinfectious glomerulonephritis.
			D)	Henoch-Schonlein purpura.
			E)	Autosomal recessive polycystic kidney disease.
3		From the BLOOD culture, you expect to find:
			A)	Shigella species.
			B)	Escrichihea coli.
			C)	Streptococcus pneumoniae.
			D)	No bacteria.