Dr Ranjith Kumar Dr S.Balasubramanian Unit KKCTH
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1 Dr Ranjith Kumar Dr S.Balasubramanian Unit KKCTH
2 4yrs old female child Neuroblastoma Left suprarenal Under went Nephrectomy (24/04/2009 ) Received chemotherapy (12 cycle) + Radiotherapy(6/1/2010)
3 Difficulty in walking x 1month (17/02/10) No symptoms of sensory loss Bowel & Bladder normal
4 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
5 Gait : Broad based gait,no swaying Cerebellum : Romberg sign : negative Spine : normal
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8 Post chemotherapy + Nephrectomy status Broad based gait Gower sign Positive Normal sensory system Normal bowel & Bladder function
9
10 Drug induced Endocrinal Hypothyroidism Hypoparathyroidism Paraneoplastic syndrome Hypophospatemia Fanconies due to drugs Pyomyositis Steroid induced/cushing syndrome Vitamin D deficient Rickets
11 CBC: normal EMG & NCV = Normal RFT normal (no Hypokalemia, N.ionised Ca) LFT
12 Ca Po4- SAP Hco3- TRP PTH Vit D 25/11/ /1/ /2/ N /3/ /4/ /7/
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14 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
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16 Chemotherapy related Rickets No sun exposer No routine vitamin D supplementation DIAGNOSTIC DILEMMA Tumour induced phosphoturia / Vitamin D deficiency Rickets
17 THANK YOU
18 Abstract A 7-year-old boy developed renal tubular dysfunction and hypophosphatemic rickets following treatment for relapsed embryonal rhabdomyosarcoma. Multiagent chemotherapy included ifosfamide; the child received a total of 108 g/m 2. 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 Wiley-Liss, Inc.
19 *AJR 158: , April X/92/ American Roentgen Ray Society
20 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,pelvic deformities Diagnosis: osteomalacia sec. to vitamin D deficiency from lack of sun light exposer & inadequacy of diet
21 Pub med 2010 Aug 15;500(2) Arch Biochem Biophys Muscle weakness in rachitic patient is result of hypophosphatemia of vitamin D deficiency
22 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 g/m 2 are important risk factors for nephrotoxicity.
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24 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
25 All Children with cancer (chemotherapy +/- steroids )need Vitamin D supplementation Vitamin D supplementation known to reduse risk of some adult cancers like Colorectal,Brest,Prostate etc,.
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