PE due to fluid overload secondary to renal failure in a tod
The following case has been reported in BMJ.

A 15-month-old toddler presented to the emergency department (ED) with a history of fatigue, rhinitis and reduced oral intake. The medical history was remarkable for diarrhoea (Enterohaemorrhagic Escherichia coli (EHEC), Shiga toxin) positive haemolytic uremic syndrome (D+-HUS) 3 months ago with microangiopathic haemolytic anaemia, thrombocytopenia, renal failure and hypertension.

When HUS was diagnosed, he had a blood pressure of 117/82 mm Hg, anuria over 18 hours and a platelet count of 110x109/L with fragmentocytes on blood film without evidence of complement dysfunction. The patient had come off dialysis after 1 month with persistent impaired renal function (peak creatinine 300 µmol/L, on discharge 205 µmol/L, estimated glomerular filtration rate (eGFR) 10 and 15 mL/min/1.73 m2, respectively).

He was on regular amlodipine, calcitriol and sodium bicarbonate. Parents reported normal urine output. Clinical examination showed respiratory rate 62/min, no recessions, heart rate 154/min, blood pressure 122/98 mm Hg, pulse oximetry 100% and normal temperature. Lung auscultation revealed bilateral inferior crackles; heart auscultation was normal except for a louder second heart sound. Liver was not palpable and peripheral oedema was absent. Chest X-ray, blood count and serum chemistry were ordered.

Imaging (supine) shows marked bilateral perihilar interstitial opacities, Kerley B lines on the left lateral inferior lung, no effusions and normal heart size (figure 1). Laboratory results indicated anaemia (haemoglobin 7 g/dL), elevated serum creatinine (259 µmol/L, normal <31, eGFR 12 mL/min/1.73 m2) and mild hyperkalaemia (5.6 mmol/L).

The patient was diagnosed with pulmonary oedema due to fluid overload secondary to renal failure and transferred for ultrafiltration and dialysis to a tertiary centre.

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