What is the most appropriate management for a 2-year-old boy with stuttering without behavioral changes?
Correct Answer A:
The first signs of stuttering tend to appear when a child is about 18 to 24 months old and starting to put words together to form sentences. To parents, the stuttering may be upsetting and frustrating, but it is natural for kids to do some stuttering at this stage of development.
A child may stutter for a few weeks or several months, and the stuttering may be sporadic. For most kids who begin stuttering at the of age of 3-8 years, the stuttering eventually resolves within 4 years in 75% of cases, without any need for intervention such as speech or language therapy. However, if the child's stuttering is frequent, continues to get worse, and is accompanied by body or facial movements, it's a good idea for a speech language therapist to evaluate your child before he or she is 3 years old.
Normal Stuttering:
Mild Stuttering:
Severe Stuttering:
→ Refer mild and severe stuttering to speech pathology.
→ There's no need for ENT of neurology referral, as this patient suffers from developmental stuttering; not neurogenic stuttering (acquired stuttering due to neurologic trauma).
→ In a recent study, researchers concluded that drug therapy has been largely ineffective in controlling stuttering.
Which of the following statements about stuttering in a 4-year-old is incorrect?
Correct Answer B:
The etiology of stuttering is controversial. The prevailing theories point to measurable neurophysical dysfunctions that disrupt the precise timing required to produce speech. Stuttering is a common disorder that usually resolves by adulthood. Almost 80% of children who stutter recover fluency by the age of 16 years. As with many behavioral disorders of childhood, stuttering occurs three to four times more often in boys than in girls. Mild stuttering is self-limited, but more severe stuttering requires speech therapy, which is the mainstay of treatment. Delayed auditory feedback and computer-assisted training are currently used to help slow down speech and control other speech mechanisms. Pharmacologic therapy is seldom used, although haloperidol has been somewhat effective.
A 6-year-old female patient is brought in by her mother because the girl’s urine has been red since this morning. She refers to you that the patient had an upper respiratory tract infection 1 week ago, from which she seemed to have recovered. She also reports noticing that the girl seems to have gained weight in the past day. On physical examination her vital signs are: blood pressure of 150/90 mmHg, and heart and respiratory rate within the normal range for her age.
As you examine her, you notice that she has lower limb edema, that seems to extend to the abdominal area. You also find facial edema. With these findings you decide to order a urinalysis which reveals hematuria with red blood cell casts and proteinuria (+). Her blood creatinine is slightly elevated.
Which of the following patterns would you expect to find in her serum complement levels?
Correct Answer D:
The clinical scenario described above would point to a diagnosis of Nephritic Syndrome. The most likely cause of it in this particular patient would be Postinfectious Glomerulonephritis, which is caused by prior infection with specific nephritogenic strains of group A beta-hemolytic streptococcus. This disease tends to affect children between 5 and 12 years old, as well as adults over 60 years of age.
Typically, it would take between 1 and 3 weeks to develop postinfectious glomerulonephritis after having pharyngitis, while it would take between 3 and 6 weeks after having a skin infection.
The clinical manifestations usually include, gross hematuria, edema and hypertension. Laboratory findings include: hematuria with or without red cell cast and non-nephrotic range proteinuria in the urinalysis; increase in creatinine level; and low C3 and normal C4 complement levels (choice D). Anti-streptolysin (ASO), Anti-hyaluronidase (AHase), Anti streptokinase (ASKase), Anti-nicotinamide-adenine dinucleotidase (anti-NAD) and Anti DNAse B antibodies are also positive in most of the cases 90 percent in pharyngitis and 80 percent in skin infection).
→ Normal C3 level and normal C4 level (choice A) could be found in IgA nephropathy.
→ Low C3 level and low C4 level (choice B) could be found in Systemic Lupus Erythematous.
→ Normal C3 level and low C4 level (choice C) could be found in Membranoproliferative glomerulonephritis.
→ Very high levels of C3 (choice E) can be found in hematologic malignancies, although it is not common.
Out of these, the only pattern that could rarely be found in a patient with Postinfectious glomerulonephritis is Normal C3 and Normal C4. However, 90 percent of the cases show low C3 and normal C4.
Key point:
Due to the immunologic nature of postinfectious glomerulonephritis, complement levels are commonly affected showing low C3 level and normal C4 level. This aids in the differential diagnosis of a patient with clinical manifestations of Nephritic Syndrome.
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