A 30-month-old child, born at term, scheduled cesarean section, controlled pregnancy, weight and height according to gestational age.
Antecedents of two episodes of mental illness, without surgery, previous hospitalization or allergies.
Complete immunisations according to the official schedule.
Normal growth and development.
Family history with both obese parents with bariatric surgery performed, and two older sisters with a history of asthma and hypothyroidism, respectively.
The patient was referred to our hospital with edematous ascites syndrome.
The patient started a week earlier with mild bilateral epiphyseal edema.
Two days later, the patient developed a non-pruriginous generalized urticarial exanthema throughout the body that reverted spontaneously within 24 hours.
At 48 hours, a more pronounced bipalpebral edema, abdominal distension and irritability appeared.
The pediatrician was consulted, who found an increase of 2 kg compared to previous weight (2 months before).
She had no history of infection.
She was referred to a nephrologist, who requested laboratory studies whose results showed marked hypoproteinemia and hypoalbuminemia, hypertriglyceridemia, mild hypocalcemia and normal urine.
The child was referred to our hospital for diagnosis and treatment.
Physical impairment: wet, alert, oriented, irritable child.
TA 109/78 mm Hg, TAM 92 mm Hg, HR 130 bpm, RR 32 bpm, temperature 36.7°C, O2 saturation 96% breathing room air.
His weight was 14,600 kg, generalized paleness, abotaged facies.
Epidermitis, bilateral.
Some basal crackles in both lung fields.
Bilateral pretibial oedema.
The abdomen was distended, with a positive ascitic wave, without hepatomegaly.
Elevated liver function tests
The rest of the exam did not present particularities.
Initial laboratory: leukocytes: 17 700/mm3, formula: 27% neutrophils, 14% eosinophils, 49% lymphocytes, 6% monocytes and 4% atypical lymphocytes.
Total calcium 7.4 mmol/L (VN 8.5-10), total protein 3 g/dl (VN 6.6-8.7), albumin 1.6 g/dl (VN 3.5-3), IgG 14090-1dl (GVN 196
Total cholesterol 129 mg/dl (VN < 200), HDL 25 mg/dl (VN > 35).
PCR 1.3mg/dl (VN < 0.06).
Normal urine without proteinuria
Prot/Cr ratio 0.26.
Normal thyroid hormones and negative celiac disease antibodies
Tuberculin skin test was negative.
On the second day of hospitalization, the child presented two feverish peaks, congestive fauces, mild biphasic pulmonary subcrepitants.
Chest X-ray and renal ultrasound showed no particularities.
Abdominal ultrasound showed no visceromegaly, moderate ascitic fluid, gastric mucosa without enlargement or hypertrophy of folds.
The cardiovascular, renal or hepatic etiology was ruled out by the clinic and the studies performed.
suspicious of perfidious presence of gastrolipodenal protein endoscopy was performed with biopsy. The report revealed: oesophagus with mucosal change at 23 cm, pale mucosa and mucous fold edema.
Dye with thickened folds and mucous edema.
The biopsy report corresponded to colitis, gastritis and mild to moderate chronic duodenitis with frequent eosinophils.
The α1-antitrypsin clearance was not performed due to the lack of accessibility to the method.
1.
IgM-IgG for CMV was requested in blood: positive; early antigen: reactive; PCR: 2075 copies (non-reactive < 750 copies).
Biopsy material was not analyzed for virus detection.
The patient underwent a hyperproteic and gastroprotective diet.
She received an intravenous infusion of albumin (25% 1 g/kg, 1 dose), 20 mg/day administered intravenously, and 3 mg/kg/day administered orally.
After no clinical improvement, intravenous administration of ganvir (5 mg/kg every 12 hours) was started 6 days later.
After 48 hours, valganvir was administered orally (400 mg/day) due to the impossibility of maintaining venoclysis.
After 10 days of hospitalization, due to the good evolution, the patient was discharged.
Laboratory at discharge: total proteins 4.6 g/dl (VN 6.6-8.7), albumin 2.6 g/dl (VN 3.5-5), triglycerides 254 mg/dl (VN < 150).
CMV viral load < 750 copies.
It was indicated to continue with high protein diet, gastric protectors and valganvir orally until completing 6 weeks of treatment.
Four months later, gastroduodenal endoscopy was repeated and the result was normal.
