From the Research
The most appropriate next step in management is paracentesis (option E). This 6-year-old boy with nephrotic syndrome presents with fever, vomiting, abdominal pain, abdominal distention, diffuse tenderness, and a fluid wave, suggesting peritonitis with ascites. Given his immunocompromised state from prednisone therapy, he is at high risk for spontaneous bacterial peritonitis. Paracentesis would allow for sampling of the peritoneal fluid to identify potential pathogens and guide antibiotic therapy. The patient's elevated white blood cell count with neutrophil predominance strongly suggests infection. While blood cultures have been ordered, paracentesis provides direct access to the likely site of infection. This is crucial because spontaneous bacterial peritonitis in nephrotic syndrome patients can be life-threatening and requires prompt diagnosis and treatment. The other options would not address the urgent need to diagnose and treat the likely peritoneal infection in this immunocompromised child with signs of systemic inflammation, as supported by recent studies such as 1, which emphasizes the importance of early diagnosis and treatment in improving patient outcomes.
Key points to consider in this case include:
- The patient's clinical presentation, which is suggestive of peritonitis with ascites
- The patient's immunocompromised state due to prednisone therapy, which increases the risk of spontaneous bacterial peritonitis
- The importance of prompt diagnosis and treatment of spontaneous bacterial peritonitis, as highlighted in studies such as 2 and 3
- The role of paracentesis in diagnosing and guiding treatment of spontaneous bacterial peritonitis, as discussed in studies such as 4 and 5
Overall, the most recent and highest quality evidence, such as the study published in 2018 1, supports the use of paracentesis as the most appropriate next step in management for this patient.