Dr Ranjith Kumar

Dr S.Balasubramanian Unit

KKCTH

4yrs old female child

Neuroblastoma Left suprarenal

Under went Nephrectomy (24/04/2009 )

Received chemotherapy (12 cycle) +

Radiotherapy(6/1/2010)

Difficulty in walking x 1month (17/02/10) No symptoms of sensory loss Bowel & Bladder – normal

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

Gait : ▪ Broad based gait ,no swaying

Cerebellum :▪ Romberg sign : negative

Spine : 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

CBC: normal EMG & NCV = Normal RFT –normal (no Hypokalemia, N.ionised Ca) LFT

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

THANK YOU

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.

*AJR 158:823-824, April 1992 0361-803X/92/1 584-0823 © American Roentgen Ray Society

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

All Children with cancer (chemotherapy +/-steroids )need Vitamin D supplementation

Vitamin D supplementation known to reduserisk of some adult cancers like Colorectal,Brest,Prostate etc,.