Incidental chronic kidney disease in an obese child with high myopia: Questions
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CLINICAL QUIZ
Incidental chronic kidney disease in an obese child with high myopia: Questions Aliza Mittal 1
&
Manjesh Jayappa 1 & Binit Sureka 2 & Kuldeep Singh 1
Received: 31 July 2020 / Revised: 7 August 2020 / Accepted: 15 September 2020 # IPNA 2020
Keywords Child . Obesity . Knock-knees . Myopia . Nephrocalcinosis . Chronic kidney disease
Case summary A 12-year-old boy was referred for high creatinine (serum creatinine 2.1 mg/dl) detected on a pre-anesthetic checkup for orchidopexy after testicular torsion. There was no history of abdomen pain, hematuria, recurrent urinary tract infection, reduced urine output, rashes, or edema. However, he had complaints of polyuria and polydipsia over the last 5–6 months for which routine causes like urinary tract infection and diabetes mellitus were ruled out by the primary physician, but no therapy had been advised. There was no history of intake of nephrotoxic medications or anabolic steroids. The child was a product of nonconsanguineous marriage and second in birth order. He developed high myopia at 4 years of age and was using glasses for the same since then; however, there was no visual loss. Further, at the age of 11 years, he was noted to have knockknees. The child had been prescribed vitamin D 60,000 IU, for 4 weeks in view of suspected rickets 1 year ago, of which he had taken almost 15 sachets (900,000 IU). On examination, the child was obese (BMI 30.33 kg/m2) and had knock-knees. There was no edema, rashes, or pallor. Blood pressure was 110/76 mmHg (normal) and other vitals were within normal ranges for his age. There were no dysmorphic features. On ocular examination, anterior segment was The answers to these questions can be found at https://doi.org/10.1007/ s00467-020-04785-z. * Aliza Mittal [email protected] 1
Department of Paediatrics, All India Institute of Medical Sciences, Room No. 3146, Medical College Block, Jodhpur, Rajasthan 342005, India
2
Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
normal but there was high myopia. Vision was 6/12 bilaterally with glasses ((RT − 14.0 D/L − 14.50 D) for which the child was using corrective glasses (RT − 13.5 D/L − 14.25 D)). No pigment deposits were present on the retina. There were no other abdominal, cardiac, respiratory, or neurological findings on examination. Evaluation for raised creatinine was followed up. Abdominal ultrasound was suggestive of bilateral nephrocalcinosis which appeared as dense calcific deposits on X-ray KUB (Fig. 1). His labs showed the following results after initial evaluation for nephrocalcinosis (Table 1). It was inferred that the child had anemia (due to iron deficiency) with raised urea and creatinine with an eGFR of 31 (chronic kidney disease (CKD) stage 3) with hyperparathyroidism, and normal vitamin D levels and hypomagnesemia with hypercalciuria and hyperuricemia and sub-nephrotic proteinuria.
Questions 1. What are the clinical diagnostic possibilities in this child presenting with such neph
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