An adolescent presenting with acquired acute renal damage: Questions

Excerpt

A 16-year-old girl was admitted to the pediatric nephrology department following testing that detected azotemia and headache. She was the fourth child of the fourth pregnancy of non-consanguineous parents, and her past medical history was unremarkable. There was no history of renal disease in the family. Her height was 166 cm (75th percentile), weight was 56 kg (50th percentile), and blood pressure was 115/65 mmHg (95th percentile 128/78 mmHg). There was no evidence of dehydration or edema. Her physical examination was unremarkable. The results of the laboratory examination were: hemoglobin, 8.4 g/dl; leukocytes, 3200/mm³; platelets, 184,000/mm³; ferritin, 25 (normal range 11–306) ng/ml; blood urea nitrogen (BUN), 108 mg/dl; serum creatinine, 14.8 mg/dl; sodium, 117 mEq/L; potassium, 13.6 mEq/L; calcium, 8.93 mg/dl; phosphorus, 16.1 mg/dl; uric acid, 14.9 g/dl. Daily urine volume was 1650 ml/m²/day. The results of her urine analysis were: pH 5, density 1029, leukocyte esterase and nitrite negative and 12 leukocyte/HPF. Neither proteinuria nor hematuria was observed. Although she had hyperkalemia, the T wave, PR distance and QRS complex data were normal on electrocardiography (ECG) (Fig. 1). The laboratory tests were repeated in the intensive care unit (ICU) because this level of serum potassium was considered to be incompatible with life but the ECG findings were normal. Upon admission to the ICU, BUN was 11 mg/dl, serum creatinine was 0.78 mg/dl, sodium was 139 mEq/L, potassium was 4.8 mEq/L, calcium was 9 mg/dl, phosphorus was 4.3 mg/dl and uric acid was 5.8 g/dl. In the meantime, a large number of viable bacilli and cells similar to epithelial cells with a large cytoplasm were observed on peripheral blood smear prepared from the first sample (Fig. 2). Her acute phase reactants were normal, and she was also afebrile. Blood tests performed the next day were similar to those at the time of admission.

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