Idiopathic intracranial hypertension as rickets unusual manifestation establishing diagnosis through a skeletal survey imaging

Idiopathic intracranial hypertension as rickets unusual manifestation: establishing diagnosis through a skeletal survey imaging A Tjan, P Putu Yuli Anandasari, E Dwi Martadiani, P Aditha URL : https://onlinelibrary.wiley.com/doi/10.1111/1754-9485.12658 Sanglah General Public Hospital, Denpasar, Bali, Indonesia Learning Objectives: To increase awareness of any various unusual clinical manifestation of rickets, and skeletal conventional imaging modality solely can establish the diagnosis of rickets. Background: Rickets is the most common cause of bone mineralization disruption in children with vitamin D deficiency and malnutrition remains a major health problem in Indonesia. Prevalence of nutritional rickets placed among the 5 most common diseases in children in developing regions. Idiopathic intracranial hypertension is a rare syndrome characterized by unknown cause of elevated intracranial pressure with absence of ventriculomegaly, abnormality of brain parenchyma, normal cerebrospinal fluid cell count and protein count. Rickets is diagnosed based on classical clinical finding, in conjunction with laboratory and radiology result. Skeletal survey using X-Ray as the solely imaging modality used to achieve significant findings in diagnosing rickets. Herein we report an unusual presenting symptom of rickets on outpatient clinic. A 9 years old male presented with vomiting, nausea, and headache. Upon examination abnormal figure and shorter height than the usual age were seen. On examination, he was hemodynamic stable, short stature, weight and head circumference below normal as well as global developmental delay. He had khypo-scoliosis, bowing extremity and genu valgus, with other physical examination within normal. CT Scan was ordered to rule out parenchymal abnormalities, with additional body contour abnormality, thus a skeletal survey was made. Imaging Findings OR Procedure Details: A computed tomography scan (CT-Scan) was performed and turned out normal. Skeletal survey revealed global delayed bone development with generalized osteopenia with lots of long and flat bones deformities and joint dislocations. Skull x-ray showed widening of sella turcica, with thumb printing phenomenon on calvaria. Frying sign, widening of growth plate, and bowing deformity, were observed. Cupping sign on the chest were found. Acetabulum irregularities and slipped of both femoral head detected, as well as compression and kypho-scoliosis of thoracolumbar were discovered, and bone age was match to 4 years old boy. Laboratory test of renal function, liver function, thyroid hormone, FSH and LH was normal. Vitamin D 25-OH and phosphate was markedly decreased. Conclusion: An awareness of any various unusual clinical manifestations of rickets should be increased. X-ray solely as the imaging modality can be used to confirmed the diagnosis with additional examination such as CT Scan to rule out another underlying aetiologies. References 1. Zaki S, Lad V, Abdagire N. Vitamin D deficiency rickets presenting as pseudotumor cerebri. Journal of Neurosciences in Rural Practice. 2013;4(4):464. 2. Aboul Enein H, Abo Khair A. Idiopathic intracranial hypertension in children: Clinical presentations and management. Middle East African Journal of Ophthalmology. 2008;15(3):113. 3. Johnston I, Owler B, Pickard J. The Pseudotumor Cerebri Syndrome: Pseudotumor Cerebri, Idiopathic Intracranial Hypertension, Benign Intracranial Hypertension and Related Conditions. Cambridge: Cambridge University Press; 2007:1–356. 4. Karunakara, B. P.; Sharanabasavesh, M.; Maiya, P. P.; Mallikarjuna, H. B. Convulsions as primary manifestation of nutritional rickets. Al Ameen Journal of Medical Sciences;2013; 6 (3), p281.