a case of acute renal failure

12 year old boy presented to pediatrician with history of fever vomiting and abdominal pain, two days back. Pediatrician was my old student and he contacted me yesterday as this boy did nt pass urine for almost 24 hours and his renal function deteriorating. He developed conjuctival bleed and his coagulation parameters abnormal. He considered possibility of leptospirosis and was put on injection crystalline penicillin and ceftriaxone yesterday itself.

He was send to us  daybefore yesterday night. 

The investigation results done from outside were

• Total count 30000,with neurtophilia 
• Hemoglobin 14 gm/ dl
• Platelet 1.5 lakh
• Liver function test Total bilirubin 0.9 mg/dl,direct 0.2mg , SGPT 60 iu,SGOT 46 iu,Total protein normal 
• Coagulation parameters INR 3 , APTT 60 
• Blood urea 90mg/dl , Creatinin 4.3 mg/dl
• ESR 26 mms /hour 
• Lepto igM was negative

On arrival , 

he was conscious , Blood pressure normal and capillary refill time 3 sec.periphery warm.
On arrival he passed 20 ml of urine, microscopy showed full of RBC.
Asked about his play and activities surroundings  and style of bath, but no exposure to dirty water ,wet surroundings.No exposure to  high risk situation for leptospirosis . Still in view of high incidence of leptospirosis we continued both the antibiotics and medical management of renal failure

I saw him yesterday morning 

His circulatory status was ok, Breathing ok, but his sensorium was altered , he was answering questions but irrelevant talks in between
Conjuctival bleed on both side, no jaundice,
Minimal puffness of face,his right foot and ankle was swollen. and his left upper limb plaster for fracture ulna few weeks back. The odema on the right foot was due to a tripping and fall while play three days back according to the mother.
Chest was clear , heart sounds normal.
Abdomen tender with free doubtful shifting dullness positive. Liver was palpable 2cm soft but tender.
He was not allowing to touch the right lower limb as there was severe pain on the dorsum of foot and calf muscle.
no focus of infections obvious. knee joints on the right side and other joints were normal
no rashes.
No tenderness on the other muscles
We continued the same management ,but send the blood samples for repeat tests
As he was totally anuric and renal function deteriorated we consulted arranged for hemodialysis

Today morning 

Circulatory status and breathing normal , but his sensorium down with irrelevant talks.

He had an episode of malena.
Small amount of urine he passed was red, which showed RBC
Interestingly the odema on the dorsum of right foot was more and spread to the right knee. There were few blebs.

I had a doubt about it , again asked the mother about it
She repeated history of fall
Most of our  super specialists  in my institution are my students and i am proud to say that all of them are best in their specialty.
It was Dr Varada our nephrologist who was called in ,first thought of the possibility of Snake bite.
Boys mother was called back and when asked again , she said " i am not sure about the fall. He only told slipping on something like twig. His sister remembered seing a snake in the vicinity.
Thinking back

Yes,

Fever , neutrophilic leucocytosis , renal failure and bleeding tendency with coagulation parameter disturbed ,our clinical  diagnosis of lepto as this time justified .Many cases of lepto getting admitted and treated both in medicine and pediatrics recently most important entiy with above features is leptospirosis .

But there were atypical features 

• The pain and tenderness were only on local area and the odema was spreading with new blebs forming which is hemorrhagic
• ESR was not high. Usually in lepto High count with neutrophilia and ESR very high 
• Platelets normal , 
• Liver function was normal 

So ?

Snake bite , eminently treatable entity , but precious time lost - fourth day now , patient already in renal failure.
Dialysis is to be continued , other supportive measures to be continued.
Is there any point in giving ASV now ?
We decided to give the benefit of doubt , Give ASV
When to give ASV?
Today , He is going to be taken for second hemodialysis .  Before or after dialysis ? will it be filtered out during dialysis?
No Dont waste time. Give ASV, dialisys wont filter the ASV .

Latest situation

Finished ASV and he is undergoing dialysis , He had FFP,,antibiotics same continued.
Other questions were
Shoud we give steroids ? Should we consider capillary leak .
The puffy eyes were there , most probably due to renal failure itself. No parotid enlargement No regional lymph node enlargement
So we did nt put on steroid

shall update

22/09

He died yesterday ie 12.30 AM.Severe bleeding manifestations,cardiorespiratory arrest severe pulmonary bleeding 

As we considered few other possibilites blood samples were collected and sent for PCR lepto ,Trying to do MAT from veterinary college

May take a few days to get the result.