A 16-year-old Indonesian boy with uncontrolled hypertension was referred from a remote area in an island to the pediatric nephrology clinic at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Twenty months prior to admission to our clinic, he experienced palpitation, diaphoresis, and left-sided chest pain without radiation, because of which he was brought to the emergency room. He experienced neither shortness of breath nor blurry vision. His blood pressure was 200/120 mmHg. The internist initiated the administration of 20 mg furosemide per oral (PO) and 12.5 mg captopril PO twice daily, together with 10 mg nifedipine PO 4 times daily. However, the patient’s symptoms and hypertension persisted, due to which his parents turned to herbal treatment and skipped further medical follow-up, although oral medications were continued.\nAs the boy’s palpitations persisted for 14 months, he was taken to another internist who prescribed 30 mg nebivolol PO every morning and 80 mg telmisartan PO every evening. Echocardiography revealed normal cardiac function. Kidney Doppler ultrasound disclosed a suspicion of right adrenal mass and kidney artery stenosis, therefore, he was referred to the pediatric nephrology clinic at our center.\nAt the clinic, he complained of palpitations with diaphoresis. We also discovered that he had lost a weight of 10 kg in the past 4 months. His BMI was 16.5 kg/m2 (undernourished with normal stature), and no skin lesions were noted (). He was hypertensive (blood pressure [BP] 140/83 mmHg) and tachycardic (heart rate (HR) 107 times/minute), with similar BP and HR values in all limbs. Other physical examinations, including neurological examinations and funduscopy, revealed normal findings. Complete blood count, random glucose levels, hepatic enzyme levels, kidney functions, urinalysis, chest X-ray, and electrocardiography were unremarkable. Pheochromocytoma was suspected due to symptoms of catecholamine secretion. However, as the urine catecholamine test was unavailable in Indonesia, the urine sample was sent to a laboratory outside the country. Simultaneously, the patient underwent abdominal magnetic resonance imaging (MRI) ( and ) and 131I-meta-iodobenzylguanidine (MIBG) scintigraphy ( and ) were ordered. 131I-MIBG scintigraphy demonstrated the uptake of pathological tracer in the right suprarenal region corresponding to an adrenal tumor without metastatic lesions. The results of urine catecholamine test, which were received subsequently, confirmed our suspicion of pheochromocytoma (), after which the administration of terazosin was initiated.\nThe boy had always been healthy with no recorded history of high BP, chest pain, or palpitations. He was the first of 3 children in his family. His father had hypertension with obesity. Hereditary diseases were not acknowledged in the family. Since the past 2 years, he had stayed at a boarding school in a remote area. He denied smoking, alcohol use, and the intake of regular medications.\nOne week prior to the surgery, bisoprolol was added to his treatment regimen. Surgery was performed using the posterior retroperitoneoscopic right adrenalectomy approach for removing the tumor ( and ). Administration of 1 mg terazosin PO was maintained until 1 week after the surgery. As his hypertension gradually resolved, terazosin was then discontinued. The results of pathological examination suggesting pheochromocytoma are presented in to . A follow-up examination conducted 6 months after the surgery showed normal and stable BP without the use of any antihypertensive medications, and no other persistent signs associated with pheochromocytoma were noted.
A 13-year-old Indonesian boy who experienced successful living-related renal transplantation (LRRT) in 2017 (his 50-year-old father was his kidney donor) has been living with normal graft function. He underwent hemodialysis (HD) in 2014 after being diagnosed with end-stage renal disease (ESRD) secondary to bilateral renal hypoplasia. He was prepared for LRRT in March 2015; however, two months prior to the procedure he was infected with the hepatitis A virus (HAV). The HAV infection subsequently resolved, and LRRT preparations proceeded. Unfortunately, seven days prior to the scheduled LRRT procedure, there was a sudden significant rise in alanine transaminase (ALT) and aspartate aminotransferase (AST) levels, resulting in cancellation of the procedure. The rise in ALT and AST levels was later revealed to be caused by HCV seroconversion (). The patient was always hemodialyzed with a single-use dialyzer, and there was no history of blood transfusions or family history of viral hepatitis; however, there was an HCV outbreak in our pediatric dialysis unit in 2015.\nIn April 2015, his liver function markers rose (AST 498 U/L, ALT 816 U/L, Gamma-Glutamyltransferase (GGT) 170 U/L) and he was subsequently diagnosed with HCV infection (viral load 3.75 × 105 IU/mL, 5.57 log IU/mL of serum HCV RNA) (). HCV RNA genotype testing was conducted using hybridization probe (The Versant HCV Genotype 2.0 Assay (LiPA), Siemens), which revealed HCV genotype 1a. A 7.3-kPa liver stiffness was observed with transient elastography (fibroscan), which was categorized as F1-F2 (mild–moderate liver fibrosis) ().\nHe received interferon-based therapy with ribavirin post-HD once a week since September 2015. Six months after treatment initiation, the HCV was undetected and his liver function normalized. However, 10 months after treatment initiation, he had HCV virological breakthrough, suggested by HCV RNA of 1.28 × 104 IU/mL (4.11 Log IU/mL), leading to cessation of interferon therapy.\nPlans for LRRT were continued and HCV treatment was set up to be given a year post LRRT when stable renal graft function was achieved. In September 2017, LRRT was conducted. One year post-LRRT, graft function was normal; thus, treatment with DAAs for chronic HCV infection was commenced. Owing to a lack of evidence regarding treatment safety with DAAs in pediatrics, we arranged a thorough discussion with the Hospital Ethics Committee to obtain parental consent. In December 2018, he began receiving sofosbuvir/daclatasvir for 12 weeks. Evaluation immediately after (March 2019), at 12 weeks (June 2019), and at 24 weeks (October 2019) following treatment cessation showed no HCV recurrence (). Adverse effects, such as mild fever, fatigue, musculoskeletal pain, decreased appetite, itching and nasal congestion, were not found during treatment with DAAs.