Vitamin deficiency and renal cortical necrosis

Abstract

Lesley Archer and colleagues1Archer L Kilburn-Toppin F Sneddon K et al.A “fussy eater” with renal failure.Lancet. 2010; 375: 696Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar report a case of renal cortical necrosis, possibly bilateral, associated with severe hyperhomocysteinaemia due to vitamin B12 deficiency in a 17-year-old woman with picky-eater behaviour. We wish to raise one point about this case.In the discussion of their Case Report, Archer and colleagues apparently did not consider that their patient could have been overexposed to mercury. The aggregate clinical signs and symptoms of their young patient (anorexia, vomiting, haematuria, proteinuria) and the occurrence of subsequent pathological conditions (microvascular thrombosis, renal cortical necrosis) resemble inorganic mercury toxicity in every respect.2Eto K Takizawa Y Akagi H et al.Differential diagnosis between organic and inorganic mercury poisoning in human cases—the pathologic point of view.Toxicol Pathol. 1999; 27: 664-671Crossref PubMed Scopus (46) Google Scholar, 3Murphy MJ Culliford EJ Parsons V A case of poisoning with mercuric chloride.Resuscitation. 1979; 7: 35-44Summary Full Text PDF PubMed Scopus (32) Google Scholar Even the laboratory findings (anaemia, hyperhomocysteinaemia, selenium deficiency) were similar to those reported in published data involving individuals with exposure to inorganic mercury.3Murphy MJ Culliford EJ Parsons V A case of poisoning with mercuric chloride.Resuscitation. 1979; 7: 35-44Summary Full Text PDF PubMed Scopus (32) Google Scholar, 4Guzzi G Pigatto PD Urinary mercury levels in children with amalgams fillings.Environ Health Perspect. 2008; 116: 286-287Crossref Scopus (5) Google ScholarMercury-induced toxic effects may appear weeks after overexposure. Clinical signs of mercury poisoning are not characteristics and delay in diagnosis is common. However, the kidney is believed to be a major target organ of mercury toxicity. Phosphorus and arsenic are also regarded as potentially nephrotoxic substances able to induce a renal cortical necrosis. Therefore, it would have been appropriate to rule out a potential metal intoxication in this interesting case of acute kidney injury.We declare that we have no conflicts of interest. Lesley Archer and colleagues1Archer L Kilburn-Toppin F Sneddon K et al.A “fussy eater” with renal failure.Lancet. 2010; 375: 696Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar report a case of renal cortical necrosis, possibly bilateral, associated with severe hyperhomocysteinaemia due to vitamin B12 deficiency in a 17-year-old woman with picky-eater behaviour. We wish to raise one point about this case. In the discussion of their Case Report, Archer and colleagues apparently did not consider that their patient could have been overexposed to mercury. The aggregate clinical signs and symptoms of their young patient (anorexia, vomiting, haematuria, proteinuria) and the occurrence of subsequent pathological conditions (microvascular thrombosis, renal cortical necrosis) resemble inorganic mercury toxicity in every respect.2Eto K Takizawa Y Akagi H et al.Differential diagnosis between organic and inorganic mercury poisoning in human cases—the pathologic point of view.Toxicol Pathol. 1999; 27: 664-671Crossref PubMed Scopus (46) Google Scholar, 3Murphy MJ Culliford EJ Parsons V A case of poisoning with mercuric chloride.Resuscitation. 1979; 7: 35-44Summary Full Text PDF PubMed Scopus (32) Google Scholar Even the laboratory findings (anaemia, hyperhomocysteinaemia, selenium deficiency) were similar to those reported in published data involving individuals with exposure to inorganic mercury.3Murphy MJ Culliford EJ Parsons V A case of poisoning with mercuric chloride.Resuscitation. 1979; 7: 35-44Summary Full Text PDF PubMed Scopus (32) Google Scholar, 4Guzzi G Pigatto PD Urinary mercury levels in children with amalgams fillings.Environ Health Perspect. 2008; 116: 286-287Crossref Scopus (5) Google Scholar Mercury-induced toxic effects may appear weeks after overexposure. Clinical signs of mercury poisoning are not characteristics and delay in diagnosis is common. However, the kidney is believed to be a major target organ of mercury toxicity. Phosphorus and arsenic are also regarded as potentially nephrotoxic substances able to induce a renal cortical necrosis. Therefore, it would have been appropriate to rule out a potential metal intoxication in this interesting case of acute kidney injury. We declare that we have no conflicts of interest. Vitamin deficiency and renal cortical necrosis – Authors' replyWe would like to highlight that the vitamin B12 measurements published in our Case Report were incorrect. The original measurements were 98 ng/L (72·3 pmol/L) for vitamin B12 (normal range 140–900 ng/L [103·3–664·2 pmol/L]) and 2·0 μg/L (4·5 nmol/L) for folate (normal range 2·0–20·0 μg/L [4·5–45·3 nmol/L]). We apologise for the incorrect conversion to SI units. Full-Text PDF