Exploring pearls and pitfalls in the diagnosis of rickettsia among children: Mini-review and case report

Year 2023, Volume: 40 Issue: 3, 664 - 668, 30.09.2023

Basuki Supartono , Hutri Mahardika

Abstract

Rickets, a condition causing softening of bones in children, is prevalent in developing regions like the Middle East, Africa, and Asia. Diagnosis of rickets can be challenging due to their non-specific symptoms, often resembling other infectious or inflammatory diseases. Nevertheless, early detection and treatment of rickets remain a global priority. Hence, gaining valuable insights into its clinical presentation, diagnostic complexities, treatment options, geographical distribution, and preventive measures is essential to ensure improved healthcare for affected children.We present a case of a 10-year-old female patient who was brought to the hospital with a history of frequent falls while playing and experiencing leg pain. The patient had poor eating habits, disliked snacking, and was not exclusively breastfed. Physical examination revealed her legs being shaped like the letter "X," with hyperlaxity and a genu valgum posture. Laboratory results indicated low levels of inorganic phosphorus and total vitamin D 25-OH. The X-ray examination showed Erlenmeyer Flask Deformity, bilateral genu valgum, bilateral distal femur, and proximal tibia metaphyseal widening deformities, and no fractures or other deformities. The patient was diagnosed with rickets and promptly treated with calcium, vit D3, multivitamin syrup, and a high protein, high-calorie diet. After one month of treatment, the patient reported reduced pain, improved balance, and fewer falls.Rickets can be prevented through effective education of parents and pregnant women about calcium and vitamin D-rich food sources and the significance of sun exposure. Pregnant women should be advised to receive a daily intake of 600 IU of vitamin D. For breastfed infants and those consuming less than 500 mL of fortified formula daily in their first year of life, oral vitamin D supplementation of 200-400 IU per day is recommended.

Keywords

Rickettsia, children, diagnosis, risk, case report

Supporting Institution

RS Al Fauzan Jakarta, UPN Veteran Jakarta

Project Number

1

Thanks

Department of Orthopedics, Faculty of Medicine, UPN Veteran Jakarta, Indonesia Department of Orthopedics, Al-Fauzan General Hospital, East Jakarta, Indonesia

References

• 1. Alzahrani AA. Perception of Rickets Disease Among Parents in Al-Baha Province, Saudi Arabia. Int J Gen Med. 2022;15:5043–9.
• 2. Pettifor JM. Nutritional rickets: deficiency of vitamin D, calcium, or both? Am J Clin Nutr. 2004;80(6):725S–9S.
• 3. Haffner D, Leifheit-Nestler M, Grund A SD. Rickets guidance: part I-diagnostic workup. Pediatr Nephrol. 2022;37(9):2013–36.
• 4. Ogunmwonyi I, Adebajo A WJ. The genetic and epigenetic contributions to the development of nutritional rickets. Front Endocrinol. 2022;13.
• 5. Carpenter TO, Shaw NJ, Portale AA, Ward LM, Abrams SA PJ. Rickets. Nat Rev Dis Prim. 2017;3.
• 6. Bakeit, ZA. Megeid F. Study of Risk Factors of Rickets in Children. Semant Sch. 2013;
• 7. Shahnaz, Pervin & Hasan M. Risk Factpr for Nutritional Rickets among 0-5 Years Children in Bangladesh. IOSR J Pharm Biol Sci. 2018;13(2):33–9.
• 8. Charoenngam N, Ayoub D, Holick MF. Nutritional rickets and vitamin D deficiency: consequences and strategies for treatment and prevention. Expert Rev Endocrinol Metab. 2022 Jul 19:1-14. doi: 10.1080/17446651.2022.2099374.
• 9. Shah TH, Hassan M, Siddiqui TS. Subclinical nutritional rickets among adolescents in Kaghan Valley. J Coll Physicians Surg Pak. 2014 Sep;24(9):663-5. PMID: 25233972
• 10. Simm PJ, Munns CF, Jefferies CA, Wheeler BJ. Editorial: Childhood Rickets-New Developments in Epidemiology, Prevention, and Treatment. Front Endocrinol (Lausanne). 2020 Nov 23;11:621734. doi: 10.3389/fendo.2020.621734. PMID: 33329409; PMCID: PMC7719773
• 11. Akila Devi V , Thangavelu S VM. Renal Rickets – Pediatrician's Perspective. Indian J Pract Pediatr. 2017;19(2):156.
• 12. Jaiman, A. Tiwari, L. Prakash, J. Jaiman A. A practical approach to diagnose and treat rickets. J Clin Med Kazakhstan. 2021;18(1):2–7.
• 13. Abdullah Hashim SH, Alenezi NA, Zeid Aldakkan O, Tinan Alenezi MA, Khalid A. Overview of epidemiology and management of rickets among children in Saudi Arabia. Journal of Clinical Images and Medical Case Reports. 2021;2(5). doi:10.52768/2766-7820/1311
• 14. El Sayed SA, Nezwek TA VM. Physiology, Bone. Statpearls. 2022.
• 15. Siddiqui, JA. Partridge N. Physiological Bone Remodeling: Systemic Regulation and Growth Factor Involvement. Physiology. 2016;31:233–45.
• 16. Bouillon R, Manousaki D, Rosen C, Trajanoska K, Rivadeneira F RJ. The health effects of vitamin D supplementation: evidence from human studies. Nat Rev Endocrinol. 2022;18(2):96–110.
• 17. Haffner D, Leifheit-Nestler M, Grund A SD. Rickets guidance: part II- management. Pediatr Nephrol. 2022;37(10):2289–302.
• 18. Charoenngam N, Shirvani A HM. Vitamin D for skeletal and non-skeletal health: What we should know. J Clin Orthop Trauma. 2019;10(6):1082–93.
• 19. Chang SW LH. Vitamin D and health - The missing vitamin in humans. Pediatr Neonatol. 2019;60(3):237–44.
• 20. Arshad, S., Zaidi SJA. Vitamin D levels among children, adolescents, adults, and elders in Pakistani population: a cross-sectional study. BMC Public Health. 2022;22.
• 21. Antonucci R, Locci C, Clemente MG, Chicconi E AL. Vitamin D deficiency in childhood: Old lessons and current challenges. J Pediatr Endocrinol Metab. 2018;31(3):247–60.
• 22. Ruiz-Ojeda, FJ. Anguita-Ruiz, A. Leis, R. Aguilera C. Genetic Factors and Molecular Mechanisms of Vitamin D and Obesity Relationship. Ann Nutr Metab. 2018;73(2):89–99.
• 23. Dahash BA SS. Rickets. Statpearls. 2022.
• 24. Blom A, Warwick D WM. Apley & Solomon's system of orthopedics and trauma. 10th ed. CRC Press; 2018.
• 25. Paludan CG, Thomsen KKV, Rahbek O, Kold S. Complications of orthopedic treatment in patients diagnosed with X-linked hypophosphatemic rickets. J Pediatr Endocrinol Metab. 2022 Jun 14;35(8):1003-1009. doi: 10.1515/jpem-2021-0775. PMID: 35700440
• 26. Huang H, Li Y, Cao Y. The Development of Rickets in Children and Nursing Contributions to Treatment. Altern Ther Health Med. 2022 Jan;28(1):86-91. PMID: 34453505
• 27. Chanchlani R, Nemer P, Sinha R, Nemer L, Krishnappa V, Sochett E et al. An Overview of Rickets in Children. Kidney Int Reports. 2020;5(7):980–90.
• 28. Fukumoto et al. Pathogenesis and diagnostic criteria for rickets and osteomalacia —Proposal by an expert panel supported by the Ministry of Health, Labour and Welfare, Japan, The Japanese Society for Bone and Mineral Research, and The Japan Endocrine Society. Endocr J. 2015;62(8):665–71.
• 29. Munns C, Shaw N, Kiely M, Specker B, Thacher T, Ozono K et al. Global consensus recommendations on prevention and management of nutritional rickets. Pediatrics. 2016;56(1):60–3.
• 30. Gentile C CF. biomedicines Review Rickets in Children: An Update. 2021;23.
• 31. Thandrayen, K.; Pettifor, J. Maternal vitamin D status: Implications for the development of infantile nutritional rickets. Rheum Dis Clin N Am. 2012;38:61–79.
• 32. Kim Y. Comparison of the serum vitamin D level between breastfed and formula-fed infants: several factors which can affect serum vitamin D concentration. Korean J Pediatr. 2013;56(5):202–4.
• 33. Sakamoto R. Sunlight in Vitamin D Deficiency: Clinical Implications. J Nurse Pract. 2019;15:282–5.
• 34. Omar, M. Nouh, F. Younis, M. Nabil, N. Saat, M. Ali M. Culture, Sun Exposure and Vitamin D Deficiency in Benghazi Libya. J Adv Med Med Res. 2018;25(5):1–13.
• 35. Al-Mogbel ES. Vitamin D status among adult Saudi females visiting primary health care clinics. Int J Heal sci. 2012;6:116–26.
• 36. Agha, R., Borrelli, M. R., Farwana,R., Koshy., Altman, D. G., & Orgill, D. P. (2018). The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines. International Journal of Surgery, 60, 132-136.