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4yrs old female child
Neuroblastoma Left suprarenal
Under went Nephrectomy (24/04/2009 )
Received chemotherapy (12 cycle) +
Radiotherapy(6/1/2010)
GCS =15/15 Higher mental functions: Normal Cranial nerves: Normal Motor System: Tone – Hypotonia
Power – 4/5 all 4 limbs
No involuntary movement
DTR- normal
Plantar-bilateral Flexor response Sensory examination : normal
Post chemotherapy + Nephrectomy status Broad based gait Gower sign – Positive Normal sensory system Normal bowel & Bladder function
Drug induced Endocrinal – Hypothyroidism Hypoparathyroidism Paraneoplastic syndrome Hypophospatemia Fanconies due to drugs Pyomyositis Steroid induced/Cushing syndrome Vitamin D deficient Rickets
Ca Po4- SAP Hco3- TRP PTH Vit D
25/11/09 10.2 3.6 854
3/1/2010 1413
18/2/2010 9.7 1.8 741 17 35.6 N 9.03
11/3/2010 8.9 5.4 1840 14
22/4/2010 10.3 2.4 1832 70.1
24/7/2010 8.5 2.9 311
Treated with D OH cholecalciferol Calcium & phosphorus supplementation
After 3 months of vitamin D supplementation her gait , Serum ca, phosphorus & vitamin D level becomes normal
Chemotherapy related Rickets No sun exposer No routine vitamin D supplementation
DIAGNOSTIC DILEMMA
Tumour induced phosphoturia / Vitamin D deficiency Rickets
AbstractA 7-year-old boy developed renal tubular dysfunction and hypophosphatemicrickets following treatment for relapsed embryonal rhabdomyosarcoma. Multi-agent chemotherapy included ifosfamide; the child received a total of 108 g/m2. The complete Fanconi syndrome which ensued, including excessive loss of calcium, resolved spontaneously and progressively 18 months after the last dose of ifosfamide. The patient had no further symptoms of rickets and radiological signs had almost completely normalized. Further follow-up was not possible as, despite further treatment, the child died of progressive disease. © 1992 Wiley-Liss, Inc.
Pub med 2010 jan 16(1):34-7 By Fabbriciani et al 20yr ,vegetarian ,male
Muscle weaknesss & gait disturbance x 4yr
h/o depression confined to home for 5yrs
X ray : diffuse osteopenia ,fractures in ribs,pelvicdeformities
Diagnosis: osteomalacia sec. to vitamin D deficiency from lack of sun light exposer & inadequacy of diet
Pub med 2010 Aug 15;500(2) Arch BiochemBiophys
Muscle weakness in rachitic patient is result of hypophosphatemia of vitamin D deficiency
Ifosfamide can cause renal tubular injury manifested as Fanconi syndrome, metabolic acidosis, hypokalemia, hypophosphatemia proteinuria, and rickets.
The chronic nature of these injuries may interfere with normal growth, and close follow-up monitoring is required.
Age younger than 3 years, presence of a single kidney, and the use of a cumulative dose of ifosfamide more than 45-72 g/m2 are important risk factors for nephrotoxicity.
Cancer chemotherapy can causes Rickets Child with cancer drugs +/- steroids should
be supplemented with vitamin D Unusual presentation of Vitamin D deficiency
as Proximal myopathy