First A in APGAR
Appearance, 0 - blue/pale, 1 - pink trunk, 2 - all pink
P in APGAR
Pulse, 0 - 0, 1 - 100
G in APGAR
Grimace with stimulation, 0 - None, 1 - Grimace, 2 - grimace and cough
Second A in APGAR
Activity: 0 - Limp, 1 - Some activity, 2 - Active
R in APGAR
Respirations: 0 - None, 1 - Irregular, 2 - Regular
If a child has mastoiditis, what is the next best step in management?
CT head and neck to reveal extent of infection
Down Syndrome cancer risks
Increase ALL, Decrease solid organ tumors
Childhood Disintegrative Disorder
Normal development in early childhood then loss of acquired skills. Onset 2-10 yrs. Boys
Normal development until 2 yrs. then loss of acquired skills. Onset 2-10 yrs. Girls. Seizures
14 Days of Erythromycin (a macrolide) for pt. and close contacts
Tx for Kawasaki Dz?
IV Ig and ASA
Classic signs of peritonsillar abscess
Fever, Trismus (can't open mouth), "Hot potato" voice, Peritonsillar swelling, Uvula deviation
Ambiguous genitalia ddx?
5-alpha-reductase deficiency, Androgen Insensitivity
Behavior mod, DDAVP, Imipramine (tricyclic)
Jejunal atresia keywords
bilious, triple bubble, d/t vascular accident in utero causing intestinal necrosis
Duodenal atresia keywords
bilious 1st day of life, double bubble, d/t failure of duodenum recanalize, assoc. w/ polyhydramnios
Hirschprung disease keywords
bilious, delayed passage of meconium age >48 hrs, Dx: Rectal biopsy gold standard
Necrotizing enterocolitis keywords
bilious, bloody stool, thrombocytopenia and unstable vitals, Dx: XRAY showing intramural air
NON-bilious, projectile vomiting, 3-6 wks age, olive mass, Dx: US
What is the most common nutritional deficiency in children?
When can cow's milk be given?
Not until 1 y.o.
Infectious mononucleosis keywords
EBV, splenomegaly, posterior cervical lymphadenopathy
Leukocyte adhesion deficiency
recurrent bacterial infections, delayed umbilical cord separation, CD18 deficient, No Neutrophils in infected tissues but levels increased in blood (cause they can't migrate)
Adenosine Deaminase Deficiency
Auto Rec, deficient mature B cells and T cells d/t adenosine toxicity
Chronic Granulomatous disease
impaired respiratory burst --> ineffective intracellular killing, Dx: (-) Nitroblue Tetrazolium test --> yellow is seen (normally should be blue)
Cerebral Palsy keywords
equinovarus deformity, clasp knife resistance
galactose-1-p- uridyl transferase deficiency causing: jaundice, hepatomegaly, catarcts, hypoglycemia, Tx: Soy formula
Congenital CMV keywords
microcephaly, cataracts/chorioretinitis, periventricular calcifications, sensorineural hearing loss
22q11 microdeletion, decrease T cell production, wide set eyes, small mandible, holosystolic murmur/VSD/Tetralogy of Fallot, neonate with hypocalcemic seizures
Klinefelter (47XXY) cancer risk?
XYY males description
pectus exxcavatum, explosive tempers --> "Juvenile delinquents"
What is the most common form of inherited mental retardation?
Fragile X (CGG repeat), S&S: macrocephaly, long face/forehead, high arched palate, large ears, macro-orchidism after puberty
Methylamlonic acidemia keywords
defect of methylmalonyl-CoA --> Succinyl coA, vegan breast feeding mothers who need B12
Who do you avoid HCO3- infusion in DKA?
HypOkalemia, shifts O2 curve left, cerebral acidosis, edema
What is the routine care of a child with sickle cell dz?
Daily PCN by 2 mo., Daily Folate by 6 mo., Meningococcal and PPV23 @ 2 y.o., Morphine/Hydromorphone for pain
Intussusception keywords, Dx? Tx
Bilious, RUQ Sausage mass, Currant Jelly Heme + stool, Target sign, Cannot give Rotavirus vaccine, Dx AND Tx: Air contrast enema
remnant of omphalomesenteric (vitelline) duct, 3-6 cm size, 50-75 cm from ileocecal valve in 2 y.o. male, of gastric and pancreatic tissues causing painless hematochezia, Dx: Meckel Radionuclide scan/T-99 pertechnetate
CHARGE syndrome, pink when crying, blue when stops crying/is feeding
Tx: Chlamydial conjunctivitis
failure to pass meconium w/in first 48 hrs, assoc. with Cystic fibrosis. Tx: IVF, NG tube, surgery
Electrolyte imbalance in Cystic Fibrosis
hypOnatremic/hypoChloremic met alkalosis
Auto Rec F508 mutation leading to recurrent sinopulmonary infections, steatorrhea, nasal polyps, Dx: Quantitative Pilocarpine Iontophoresis and Sweat Cl-, Tx: Intranasal glucocorticoids, Vit. ADEK supplementation, Aminoglycosides for Pseudomonas infections
Hypothyroidism growth curve in children
normal childhood growth then abrupt falling off growth curve
Tetralogy of Fallot keywords
PROV (pulm stenosis, RV hypertrophy, Overriding Aorta, VSD), boot shaped heart, Tet spells (irritable, tachypnea, cyanosis), harsh systolic murmur @ LSB, Tx: Knee-chest which increases SVR, O2, surgical repair before 6 mo.
Rheumatic Fever keywords
Strep pyogenes (Group A beta hemolytic), J
Henoch-Schonlein purpura (anaphylactoid purpura)
IgA mediated vasculitis post viral URI with mesangium deposition
Bruton's (X-linked) Agammaglobulinemia
X-linked recessive defect in B TyKinase, recurrent pyogenic (strep pneumo, H. flu) infections, Dx: Dec. Ig GAME and B cells
Common Variable Immunodeficiency (CVID)
acquired hypogammaglobulinemia, older than Bruton's, Dx: Dec Ig GAME but normal B cell count
macroglossia, R sided hemi-hypertrophy, umbilical hernia, 11p15
First line tx. for club foot
Stretching and manipulation THEN serial casting between 3-6 mo.
Kawasaki Dz (Mucocutaneous Lymph node syndrome)
Fever >5d, polymorphous rash, cervical lymphadenopathy, bilateral non-exudative conjunctivitis, Inc. ESR, CRP, platelets, Tx: ASA + IVIg
Nurse Maid's elbow
Radial head dislocation, Tx: Hyperpronation
X-Recessive HGPRT deficiency --> mutilation, gouty arthritis
Dec UDP glucuronosyl Transferase causing disorder of bilirubin metabolism
Dec. UDP transferase., Inc. bili and encephalopathy.
What is the most common cause of neonatal sepsis from birth to 3 mo. of age?
Group B. Strep
Transient Tachypnea of Newborn
incomplete evacuation of fetal lung fluid in full term infants leading to respiratory condition, assoc. w/ C-sections, Tx: supplemental O2 PRN
Atrioventricular Canal Defect
common in Down Syn., systolic and diastolic heart mumur, split loud S2, EKG with RV hypertrophy, Cyanosis when nursing
seizures + MR + port wine stain along CNV territory, Dx: "tramline" gyriform intracranial calcifications on skull xray, Tx: seizure control, laser therapy for skin lesions
fever 104, 4 "C"s, Tx: Vit. A will dec. morbidity and mortality
Erythema Toxicum Neonatorum
Benign papules/pustules spares palms and soles that shows up first 2 wks of life, Tx: Spontaneous resolution
no lymph nodes, no tonsils, no thymic shadow, Dec. B, T, NK cells, - recurrent sinopulmonary infections, oral candidasis, persistent diarrhea, opportunistic and viral infections
X-Recessive WASP gene., Classically a young male with eczema, thrombocytopenia, purpura, and encapsulated infections, Dx: Dec. IgM, T, platelets, but Inc. IgA and E
Most common cause of 2ndary HTN in children?
Fibromuscular dysplasia, "string of beads" on renal a. angiogram (Right > Left)
Rubella "German Measles" S&S, Tx?
Congenital Diaphragmatic Hernia sequelae
pulmonary hypoplasia and HTN, polyhydramnios
S&S congenital diaphragmatic hernia
concave scaphoid abdomen, barrel shaped chest, dx: prenatal US, Tx: endotracheal intubation
Diamond-blackfan Anemia "Congenital hypoplastic anemia"
progenitor defect causing inc. RBC apoptosis, S&S: pallor, short, web neck, shielded chest, long thumbs, Dx: inc. fetal Hgb, dec. retic., macrocytic anemia, Tx: Corticosteroids
C8-T1 injury, Claw hand: wrist extended, MCP jts. hyperextended, interphalangeal jts. flexed, Horner syndrome
Erb-Duchenne "Waiter's Tip"
C5-C6 (Tip me "$5"), Dec. moro reflex, Intact grasp reflex
Most common primary bone tumor
Osteosarcoma, @ metaphysis of long bones, Dx: spiculated sunburst, periosteal elevation (Codman's Triangle), Inc. AlkPhos, Inc. LDH, Tx: Chemo and Surgical excision
Refeeding Syndrome explained
Carbs --> insulin release --> intracellular movement of K, phos, Mg --> arrythmias and cardiopulmonary failure
Transposition of Great arteries keywords
Egg on a string, Narrow mediastinum, Cyanosis
targets RBC precursors (dx: 0 Retics), lacy rash
sub-periosteal hemorrhage (limited to surface of one cranial bone --> does not cross suture lines), no scalp discoloration
Scotch tape test, Metronidazole
Esophageal atresia/Tracheoesophageal fistula
Dx: Polyhydramnios on prenatal US, distended stomach and intestines, choking and regurg with initial feeding immediately after birth, risk for chronic GERD
AutoRec excess trinucleotide repeat sequences, Abnormal Tocopherol transfer protein, S&S: wide-based gait, dec. vibration/proprioception, no DTRs on LE, high plantar arches
What is the earliest manifestion of vaso-occlusion in sickle cell anemia?
dactylitis (AKA Hand-foot syndrome)
defect in G-protein cAMP-kinase, 3 P's: precocious puberty, pigmentation (cafe au lait spots), polyostotic fibrous dysplasia
Rathke's pouch, suprasellar and inferior to optic chiasm
AutoDom CTG trinucleotide repeat in DMPK gene on Chromosome 19q13.3, Facial weakness, hand grip myotonia, inverted V-shaped lip
Duchenne Muscular Dystrophy
X-Rec deletion of Dystrophin gene on chrom Xp21, Dx: DNA blood analysis then mm. biopsy if blood samples not diagnostic, S&S: Trendelenburg waddling gait, progressive proximal mm. weakness (Gower's), calf pseudohypertrophy, death from respiratory failure
Becker Muscular dystrophy
X-Rec dystrophin gene deletion from Xp21.
recurrent sinopulmonary and GI infections and anaphylactic transfusion reactions (episodic diarrhea secondary to Giardia)
Posterior Vermis Syndrome
unbalanced gait, trunk dystaxia, horizontal nystagmus, papilledema, HA/vomiting, d/t Medulloblastoma
Fetal Alcohol Syn keywords
small palpebral fissues, smooth philtrum, small gestational age, septal defects
Congenital adrenal hyperplasia (CAH)
21-OH-lase deficiency leading to Inc. 17a-OH-progesterone, S&S: ambiguous genitalia in girls, hyponatremia, hypotension
Brick Red Urate Crystals in diapers
sign of dehydration
Tx. Lead Poisoning
Chelation: EDTA(IM) or DMSA(PO)
Berger IgA Nephropathy, Dx?
recurrent painless hematuria preceded by URI, Dx: Immune complex deposition in mesangium
Post Strep Glomerulonephritis, d/t, Dx?, Tx?
d/t GABHS (strep throat or impetigo), Dx: Dec. C3, normal C4. ASO +, anti-DNAse Abs, Tx: Fluids, diuretics, CCB for HTN
Rapidly Progressive Glomerulonephritis Dx
Goodpasture Syndrome S&S, d/t?
nephritis + pulm hemorrhage, d/t SLE, HSP
What is the most common cause of chronic stridor? S&S? Dx?
Laryngomalacia, inspiratory stridor worse when supine and when crying/feeding, Dx: laryngoscopy showing Omega shaped epiglottis
Retropharyngeal abscess, Dx?
fever, drooling, dysphagia, stridor, and muffled voice which is often polymicrobial, Dx: widened pre-vertebral space on lateral neck xrays
Croup (laryngotracheobronchitis) keywords
Steeple sign ("Up" the steeple"), barking cough, parainfluenzae virus
Tx: Racemic Epinephrine
Wilm's tumor arises from? keywords
metanephros, mass that doesn't cross midline
What does the mesonephros give rise to?
Guy parts "EVES": Ejaculatory ducts, Vas deferens, Epididydymis, Seminal vesicles
What does the paramesonephron give rise to?
Female parts: Fallopian tubes, Uterus, Vagina
cafe au lait, MACROcephaly, feeding and learning problems
bilateral acoustic neuromas, cataracts
Osteogenesis imperfecta keywords
COL1A1 mutation, osteopenia, blue sclera, hearing loss
If IV access isn't possible in pediatric emergencies what do you do?
Intraosseous access, often proximal tibia
Hypertrophic cardiomyopathy keywords
AutoDom, systolic @ LSB, increases with valsalva, decreases with hand grip/passive leg raise, Tx: BB
Vesicoureteral Reflux (VUR) Grading
I: undilated ureter, II: into ureter and collecting system, III: dilation of ureter and collecting system, IV: blunted calyces, V: tortuosity of ureter
Vesicoureteral reflux (VUR) often leads to? dx? tx?
UTIs, Voiding cystourethrogram showing retrograde flow, Tx. TMP-SMX, Nitrofurantoin
abrupt stridor, Thumb's sign "(epigloTTiTis Thumb), Haemophilus influenza type B,
Tx: Intubation. Hyperextension of neck, IV PCN, Cephalosporins, Carbapenems
Prader Willi keywords
hyperphagia and obesity
Chronic Granulomatous Disease, Tx?
-defective NADPH oxidase phagocytosis causing susceptibility to Catalase + organism (staph aureus, serratia, burkholderia, klebsiella, aspergillus), Tx: TMP-SMX and y-IFN 3x/wk
Tx. Neonatal meningitis
Ampicillin + Ceftriaxone/3rd gen ceph
poultry, eggs, turtles, watery/bloody diarrhea, gastroenteritis
Gram (-) Motile NON-lactose fermenter, watery diarrea --> bloody stool
Trichuris Trichiura "Whipworms" Dx? Tx?
often found in South East US, whipworms cause rectal prolapse, stool for ova and parasites, Tx: Albendazole
Which strains are covered by Gardasil
6, 11 --> genital warts, 16, 18 --> cervical ca.
Febrile seizure: when does it occur? Different types? Tx?
between 6 mo. and 6 y.o., Simple: 15 minutes with possible lateralizing signs, Tx: Lorazepam (if seizures last >5 min) and Fosphenytoin if that doesn't work
If a child beyond neonatal period (e.g. 5 y.o.) has herpetic lesions, what should you suspect?
Possible sexual abuse
Tx: Atopic dermatitis
topical corticosteroids (but not on face, genitalia, intertriginous), oral antihistamines
Seborrheic dermatitis ("cradle cap") keywords, tx?
greasy brown scales, Tx: Ketoconazole, low potency steroids
Neuroblastoma keywords, Dx?
adrenal gland tumor, raccoon eyes, lymphadenopathy, bluish skin, Dx: CT, MRI, Increased VMA and Homovanillic acid (catecholamines)
Vertebral abnormality, Anus imperforate, Tracheoesophageal fistula, Radial/Renal anomalies
Malrotation and volvulus, d/t, Dx? Tx
bilious vomiting, blood per rectum, incomplete intestinal rotation during development, Using upper GI series Contrast: Lig. of Treitz on R side of abdomen (Malrotation), Corkscrew/birds beak of duodenum (Volvulus); Tx: Stop enteral feeds, use NG, LADD procedure
1. Topical Benzoyl peroxide or Retin A, 2. Isoretinoin if severe
What is the most common cause of UTIs in boys? dx? Tx?
Posterior Urethral valves causing dribbling, poor stream, palpable kidneys, VCUG and postnasal USG, Bladder catheterization then Endoscopic Transurethral valve ablation
Tx ADHD. Children with ADHD often have what else?
Methylphenidate, Dextroamphetamine, Atomoxetine (SNRI), Oppositional defiant disorder, conduct disorder, anxiety, and depression
Slipped Capital Femoral Epiphysis puts obese children at risk for?
torticollis, cervical vertebrae fusion, short neck
Waardenburg Syndrome keywords
Think xmen's rogue is deaf: Sensorineural hearing loss, Partial albinism/forelock of gray hair, Heterochromic iris
Blount Disease (Idiopathic Tibia Vara) keywords
Abnormal medial Tibial epiphysis, Prominent Beaking and calcification
painless "antalgic" limp gait d/t idiopathic avascular, femoral head necrosis, often boys, limited int. rotation and hip abduction
Reye Syndrome S&S, Labs?
encephalopathy and acute liver failure (mitochondrial hepatopathy), Increased AST/ALT, PT/INR, PTT, Ammonia
Catarrhal Stage (of Pertussis) S&S
mild cough and rhinitis for 1-2 wks
Paroxysmal Stage (of Pertussis) S&S
coughing fits, inspiratory "whoop", "staccato" cough, emesis, apnea, cyanosis. all for 2-6 wks
Convalescent Stage (of Pertussis) S&S
resolution of cough and post-tussive emesis that comes after weeks to months
Pertussis Tx. and Post-exposure ppx
1 mo: Azithromycin x 7d or Erythromycin x 14d
Neimann Pick keywords
AutoRec, sphingomyelinase, no reflexes, hepatomegaly
Tay Sachs keywords
AutoRec, Hexoaminidase, hyper-reflexia
Autorec, Galacto-cerebrosidase lysosomal storage disorder
Gluco-cerebrosidase deficiency, anemia, thrombocytopenia, hepatomegaly
Hurler Syndrome keywords
Hydrolase deficiency lysosomal storage disorder, Coarse facies, hernias, cloudy cornea, hepatosplenomegaly
Biliary Atresia S&S, Dx, Tx
conjugated hyperbilirubinemia --> jaundice, dark urine, pale stool, Dx: US, Hepatobiliary Scintigraphy, Liver biopsy, Intraoperative cholangiogram is the Gold standard, Tx: Kasai Hepato-porto-enterostomy procedure
Type I Glycogen storage disease, G-6-Phosphatase deficiency, hypoglycemia, lactic acidosis, hyperuricemia, doll-like face
Pompe (acid maltase deficiency) Dz. keywords
Type II, Floppy baby, macroglossia, heart failure
Tx. Cyanide poisoning
Adverse effect of Lindane (Gamma-Benzene Hexachloride) lotion for scabies
Neurotoxicity in small infants
What is a contraindication for all vaccines?
severe allergic rxn
S&S Fetal Dilantin Exposure
midface hypoplasia, low nasal bridge, ocular HyPERtelorism, accentuated Cupid's bow of upper lip
S&S Small for Gestational Age baby
hypoglycemia, polycythemia --> Hyperviscosity syndrome
What is the tx. for Hyperviscosity Syndrome in SGA baby
Partial exchange transfusion with saline/LR
d/t, Dx, S&S? Tx
d/t surfactant deficiency secondary to prematurity,
S&S of Donor Twin in Twin-Twin Transfusion
Oligohydramnios, anemia, hypovolemia, shock
S&S of Recipient Twin in Twin-Twin Transfusion
Polyhydramnios, larger size
Potter Sequence keywords
pulmonary hypoplasia secondary to oligohydramnios, wide spread eyes, low set ears, broad nose
Caput succedaneum keywords
soft tissue swelling often presenting portion, ecchymotic, cross suture lines
Atrial Septal Defect (ASD) keywords
wide, fixed split S2 @ LSB, pulmonary stenosis murmur, thrombocytopenia
Ventricular Septal Defect (VSD) keywords
harsh, blowing, holosytolic @ LSB, diastolic apical rumble
Ebstein anomaly keywords
downward displacement of tricuspid valve causing: quadruple rhythm S3 and S4 (Triscupid Regurg), mid-diastolic murmur @ LSB, R atrial hypertrophy
Total Anomalous Pulm. Venous Return (TAPVR) keywords
obstruction to pulm. venous return, snowman venous congestion, fluffy CXR
Noonan Syndrome aka Male Turner Syndrome
short, web neck, shield chest, cryoptorchidism, pulm stenosis, pectus excavatum
What cardiac defect would you most likely see with Ehlers Danlos, Klinefelter?
Mitral Valve Prolapse, midsystolic click, @ apex
1. Mandibular central incisors, 2. Maxillary central incisors
Tx. of Phenobarbital OD
Prune Belly Syndrome S&S
pulm. hypoplasia, wrinkly abd wall, oligohydramnios
What is the most common hereditary nephritis?
Alport Syndrome (hematuria, hearing loss, ocular anomalies)
AutoRec, Cystathione B. Synthase deficiency, dislocated lenses, arachnodactyly
Werdnig-Hoffman (Spinal mm. atrophy type I) S&S
floppy baby, defective survivor motor neuron gene destroying neurons in brain and spine
Tuberous Sclerosis keywords
Ash-leaf hypopigmentation, Shagreen path over sacrum,
Prehn Sign, significance?
Lifting of scrotum, Pain gets worse --> torsion, Pain gets better --> epididymitis
cyanosis and dyspnea secondary to L to R shunting seen in large VSDs
Anemia of Prematurity, d/t
normocytic, normochromic, low retic anemia often seen in hospitalized, premature, LBW infants, d/t transition of erythropoiesis sites of neonate
Roseola Infantum (Exanthem subitum) d/t
abrupt high fever THEN centrifugal rash to extremities,
Parinaud syndrome, d/t
limited upward gaze, ptosis, Collier's sign of upper eyelid retraction, d/t pinealoma
Trachoma conjunctivitis: d/t, Dx:, Tx:
follicular conjunctivitis and neovascularization (pannus formation) in cornea, Dx: giemsa stain of scrapings,
Edwards Syndrome keywords
Trisomy "E"ighteen for EDWARDS, LBW, microcephaly
Patau Syndrome keywords
Trisomy "ThirTeen" for paTau, cleft lip, polydactyly
Developmental Dysplasia of Hip, Dx? Tx?
Normal female baby with abnormal acetabulum resulting in hip instability and uneven leg creases, Ortolani and Barlow tests, Ultrasound to confirm, Tx: Pavlik harness to splint hip in flexion and abduction
Pt. with cryptorchidism, hypospadias, aniridia, retardation should raise suspicion for what?
Wilms Tumor. Baby has WAGR (Wilms, Aniridia, GU, Retardation)
When is HepB Vaccine given?
Birth, 1-2, 6-18
When is Rotavirus vaccine given?
When is DTaP vaccine given?
2,4,6, 15-18, 4-6y
When is Hib and Pneumoccocal vaccine given?
When is Inactivated Polio vaccine given?
2,4, 6-18, 4-6y
When is influenza vaccine given?
yearly from 6 mo onward
When is MMR and Varicella vaccine given?
When is Meningococcal Vaccine given?
When is Tdap given? (Tetanus)
Substitute 1 time dose of Tdap for Td booster, then boost with Td q10y
Wilson's Disease inheritance?
reduced Copper excretion from liver leading to:
Kayser-Fleischer rings, parkinsonism, icterus, elevated AST/ALT, neurologic S&S
Tx: Penicillamine, Screen 1st Degree relatives
Tx. Lead poisoning
Tx. Iron poisoning
Subgaleal hemorrhage keywords
crosses suture lines
grows slowly over first day of life
Lab abnormalities in baby born to diabetic mother
Hypocalcemia (d/t low PTH)/Hypomagnesemia
Meconium Aspiration Syndrome
What would you see on CXR?
What complication can arise?
Term Baby with persistent respiratory distress (retractions, grunting, flaring)
CXR with bilateral patchy opacities, possible hyperinflation or pneumothorax
Persistent Pulmonary HTN --> acidosis and hypoxia and death
Posterior Urethral Valves
male infant with hydronephrosis/cortical thinning, bilateral flank mass AND an abdominal mass, may also have Potter facies and pulmonary hypoplasia
Dx to confirm: Voiding Cystourethrogram
Langerhans Histiocytosis X keywords
solitary, lytic painful long bone lesions in children
Tx: Resolve spontaneously
Precocious Puberty Tx
Leuprolide (GnRH agonist) will negative feedback on GnRH
Polyostotic fibrous dysplasia
Unilateral café au lait spots "Coast of maine border" that doesn't cross midline
Tx: Ketoconazole (estrogen synthesis blocker), Tamoxifen (anti-estrogen)
Henoch-Schonlein Purpura (HSP)
Vasculitis affecting children, 50% after URI
IgA and C3 deposition in small vessels
palpable purpura on legs, buttocks, abdominal and joint pain, hematuria
Tx: Supportive care