LAUSR

A 14-year-old South Indian Tamilian boy, who was born to non-consanguineous parents, was referred to us with complaints of cola-colored urine, periorbital puffiness, swelling of feet, decreased urine output, and rash over bilateral lower limbs that had appeared 4 weeks after starting anti-tubercular treatment. He was apparently asymptomatic 2.5 months earlier, when he developed complaints of fever, with evening rise of temperature for 2 weeks, accompanied by weight loss and poor appetite. On evaluation at another center, he was found to have bilateral cervical lymphadenopathy. There were multiple bilateral posterior cervical lymph nodes at that time that were matted, non-tender, and firm. After a trial of oral cloxacillin, which had not been successful in alleviating symptoms, he underwent fine needle aspiration cytology (FNAC) of the cervical lymph nodes which revealed granulomatous lymphadenitis (with negative Ziehl Neelsen staining for acid fast bacilli). The chest X-ray was normal. The tuberculin test was negative. In view of the possibility of tubercular lymphadenitis being the cause of pyrexia of unknown origin, anti-tubercular treatment (ATT) was initiated as per the National Tuberculosis Elimination Programme (NTEP) protocol recommended by the Government of India. He started improving after ATT; the fever spikes settled, and there was improved appetite with consistent weight gain over the next 4 weeks of ATT. However, he thereafter developed palpable pupuric rashes over both lower limbs. A diagnosis of drug-induced vasculitis was considered, and a skin biopsy was performed which showed leucocytoclastic vasculitis. ATT was withdrawn for a period of 3 days, during which his skin lesions almost disappeared. Drugs were re-introduced one by one in the order of ethambutol, isoniazid, and pyrazinamide. On day 9 of restarting ATT, he developed similar rashes again on both lower limbs. He was also noted to have arthralgia in both knees (without arthritis), cola-colored urine, swollen feet, oliguria, and periorbital puffiness. The child was referred to us at this juncture. The anthropometric evaluation revealed that he was moderately underweight (weight 33 kg, −2.63 Z score) and stunted (height 137 cm, −3.46 Z score) with mild thinness (BMI 17.6, −0.70 Z score). At admission, he was hemodynamically stable, and afebrile, with heart rate 80/min, respiratory rate 16/min, blood pressure 105/70 mm Hg, and oxygen saturation of 98%. BCG scar was present over the left upper arm. There were hyperpigmented non-palpable purpuric lesions over both lower limbs, bilateral pitting, pedal edema, and periorbital puffiness. There were no other features such as fever, malar rash, oral ulcers, alopecia, chorea, pallor, or arthritis. Tiny non-tender cervical lymph nodes were palpable, and the parents informed that these nodes were significantly smaller than the size noted a month ago. The rest of the systemic examination was unremarkable. Routine investigations were performed, including a complete blood count, urinalysis, blood urea, and serum creatinine. Investigations revealed hypoalbuminemia with nephrotic-range proteinuria (urine protein to urine creatine The answers to these questions can be found at http:// dx. doi. org/ 10. 1007/ s0046702205462-z.