371 Are these really stones?

Abstract

<h3>Introduction</h3> Nephrolithiasis’ recurrence is frequent and increases if an underlying metabolic abnormality is present. Although in up to 15-25% of affected children there is no risk factor identified, suspicion should be raised in the presence of exaggerated clinical manifestations with no reasonable explanation. <h3>Case Report</h3> A eleven-year old uncircumcised adolescent male, with a family history of IgA Nephropathy, was referred to a pediatric nephrology consultation after being seen multiple times in the emergency department with chief complaint of recurrent episodes of dysuria with emission of up to seventeen 3-4mm black calculus. He had no lumbar or abdominal pain, nor gross hematuria. On physical examination, Murphy’s sign was negative bilaterally and rectal examination was normal. His laboratory evaluation, urinalysis and ultrasound were unremarkable and did not reveal any morphological or functional alterations. A 24-hour urine collection was performed with an elevated concentration of urinary urea but no other noteworthy alterations. Homocysteine, methionine and homogentisic acid dosing were within normal ranges. Multiple laboratory evaluations of the stones weren’t able to determine its composition. No metabolic or infectious cause for a calculus was identified. Due to the recurrence of this situation he repeated both 24-hour urine collection and ultrasound with no significant results. The calculus was eventually sent to an outside laboratory and rubber elastomer was detected. Careful examination of the patient‘s past medical history revealed he had already been evaluated in a Pedopsychiatric consultation before. After determining the stones were self-induced, the adolescent was once more referred to Pedopsychiatry appointment. No further signs or symptoms of nephrolithiasis were reported. <h3>Discussion</h3> Although Factitious Diseases (FD) caused by proxy have been increasingly recognized, there is a significant less awareness that children and adolescents can intentionally falsify symptoms. Even though urinary tract involvement is rare, any unexplained medical condition warrants the exclusion of self-induced FD.