The most common manifestations of child abuse are skin lesions, such as ecchymoses, abrasions, scars and burns.1 Bone fractures, failure to thrive, subdural and retinal hemorrhage, genital injuries, subgaleal hematoma, unkempt appearance, frozen stares, human bite marks, visceral injuries, etc., are additional manifestations.
2Munchausen syndrome by proxy is a rare presentation which has recently been well described in the literature. [3][4][5] Various unusual manifestations of child abuse, such as fetal pepper aspiration, thirsting and hypernatremic dehydration, intentional microwave burns, transection and pseudocyst of the pancreas, tin ear syndrome, subcutaneous fat necrosis, etc., have also been recognized recently.6-8 These unusual symptoms deceive clinicians and prevent early diagnosis, thus endangering the life of the victim. There are very few reports in the world literature on the association of child abuse and acute renal failure induced by rhabdomyolysis.6,9-11 To our knowledge, this is the first confirmed case of child abuse with acute renal failure due to rhabdomyolysis in Saudi Arabia.
Case ReportA five-year-old Saudi girl was admitted to the hospital with a history of skin rashes for 15 days, swelling of the buttocks and thighs for three days, and fever for two days. The child had twice been seen by a primary care physician who had prescribed antibiotics and antipyretics without any improvement. She was referred to the hospital from the primary care center as a case of idiopathic thrombocytopenic purpura.The patient's past medical history was uneventful. Her mother died when she was two months old, and her father, a healthy 45-year-old office clerk, had remarried. Her maternal grandmother took care of her, while her two older full brothers lived with the father and stepmother. Her father had recently taken the child away from her grandmother to live with him. The child's stepmother was a 30-year-old housewife with a ten-month-old daughter, and the family was apparently living in harmony.On presentation at the hospital, physical examination revealed a sick, pale-looking child with multiple ecchymoses over the back, buttocks, thighs and forehead. There were some scars on the dorsum of the fingers. Her growth parameters were, however, normal, and vital signs were stable. Her thighs and buttocks were swollen and tender. There was no jaundice, lymphadenopathy or hepatosplenomegaly. The joints and oral mucus membranes were normal. Other examinations, including funduscopy, were normal.The initial laboratory results included the following: hemoglobin 74 g/L; white blood count 15. Upon admission, the patient received blood transfusion, fresh frozen plasma and antibiotics. She was found to be oliguric, and urinary catheterization was done. The first specimen of urine was dark brown in color. Dipstick test was positive for blood (4+), protein ++, specific gravity (1020), and microscopy did not show any RBC. Urinary electrolytes showed sodium of 67 mmol/L with fractional excretion of sodium more than 1%. Both...