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 14-year-old Indonesian girl who experienced successful live-unrelated renal transplantation from a 21-year-old donor in April 2017 has been living with normal graft function. In November 2014 she was diagnosed with ESRD secondary to nephrotic syndrome and started regular HD via single-use dialyzer. She had a history of repeated blood transfusions but no family history of viral hepatitis.\nShe was diagnosed with HCV infection with a high viral load (2.69 × 106 IU/mL, 6.43 log IU/mL of serum HCV RNA) and rising liver function markers (AST 180 U/L, ALT 133 IU/L, GGT 142 U/L) in September 2015 (). HCV RNA genotype testing was conducted using hybridization probe (The Versant HCV Genotype 2.0 Assay (LiPA), Siemens), revealing HCV genotype 1a. A 4.8-kPa liver stiffness was observed with transient elastography (fibroscan), which was categorized as F0-F1 (mild liver fibrosis) ().\nShe began receiving pegylated interferon and ribavirin in October 2015 prior to renal transplantation. Ten months later (August 2016), real-time PCR still showed the presence of HCV RNA (2.56 × 106 IU/mL, 5.41 Log IU/mL). In addition, she experienced thrombocytopenia—which is a side effect of interferon—resulting in termination of treatment.\nIn April 2017, she received kidney transplantation. At two months post-transplantation, she was diagnosed with post-transplant diabetes mellitus (PTDM), which manifested as a spontaneous inguinal abscess (10 × 3 × 0.5 cm), hyperglycemia (617 mg/dL), and ketonemia without acidosis. This PTDM is believed to be associated with her status as HCV-infected KTR, in addition to the side effect of tacrolimus–corticosteroid combination. PTDM resolved after tapering off methylprednisolone and seven months of insulin therapy.\nAt 20 months post-renal transplantation, graft function was normal; thus, treatment of HCV infection with DAAs was initiated. Since data about the treatment safety with DAAs in pediatrics are limited, we obtained parental consent after arranging meticulous discussion with the Hospital Ethics Committee. She started receiving sofosbuvir/daclatasvir in December 2018. HCV RNA with real-time PCR immediately after, at 12 weeks, and at 24 weeks after treatment initiation showed no HCV RNA (). There were no adverse effects during treatment with DAAs.