An 8-year-old girl is brought to the office due to enuresis. Although she has been toilet-trained since age 3, she has been wetting the bed most nights for the past 6 months. The patient has had no episodes of daytime incontinence. She goes to sleep easily at night in her own room. Her mother reports that she moves around a lot when sleeping and snores loudly. The patient is often tired after coming home from school and naps for 2 hours most afternoons. On examination, tympanic membranes are clear. The nasal septum is straight, and there is no rhinorrhea; there is tonsillar hypertrophy. There is no cervical adenopathy. The lungs are clear to auscultation and heart sounds are normal. Urinalysis is unremarkable. The patient is at greatest risk for which of the following complications?

Question

An 8-year-old girl is brought to the office due to enuresis.  Although she has been toilet-trained since age 3, she has been wetting the bed most nights for the past 6 months.  The patient has had no episodes of daytime incontinence.  She goes to sleep easily at night in her own room.  Her mother reports that she moves around a lot when sleeping and snores loudly.  The patient is often tired after coming home from school and naps for 2 hours most afternoons.  On examination, tympanic membranes are clear.  The nasal septum is straight, and there is no rhinorrhea; there is tonsillar hypertrophy.  There is no cervical adenopathy.  The lungs are clear to auscultation and heart sounds are normal.  Urinalysis is unremarkable.  The patient is at greatest risk for which of the following complications?

Quizplus · Accepted Answer

11ec25c8_d721_dc15_bc81_47e081aec083_MD0003_00 This child who was toilet-trained and now wets the bed has secondary enuresis. In the context of disturbed sleep with loud snoring, daytime fatigue, and tonsillar hypertrophy, this is likely related to obstructive sleep apnea (OSA). As in adults, OSA in children is a sleep disorder in which episodic upper airway obstruction occurs. In adults, the obstruction is usually caused by obesity, whereas in young children, it is often due to adenotonsillar hypertrophy. The obstruction results in difficulty breathing and disrupted sleep (eg, snoring, restless sleep, apnea). Daytime symptoms in children may include sleepiness (as in this patient) or manifest as inattention, learning difficulties, and behavioral problems. In addition, night symptoms in children may also include parasomnias and enuresis. The mechanism of enuresis is unclear, but it may be related to the elevated levels of B-type natriuretic peptide seen with OSA, possibly due to intermittent obstruction causing increased cardiac volume and pressure. Untreated OSA in children, as in adults, can result in serious cardiovascular complications likely related to disruption of autonomic neural control due to sympathetic activation during periods of hypoxia. Cardiovascular consequences can include systemic hypertension, tachycardia, structural heart changes (eg, right or left ventricular hypertrophy), and pulmonary hypertension, although the latter is more commonly associated with adult than pediatric OSA. (Choice A) Severe adenotonsillar hypertrophy can lead to dysphagia, but does not typically result in aspiration. (Choice B) Multiple sclerosis, which can present with internuclear ophthalmoplegia, can result in secondary enuresis or other urinary difficulties (eg, due to bladder dysfunction). However, this patient's tonsillar hypertrophy, snoring, and daytime fatigue make OSA much more likely. (Choice C) Ketoacidosis is a common complication of type 1 diabetes mellitus. Polyuria, a common presenting symptom of diabetes mellitus, can cause secondary enuresis in children. However, diabetes mellitus would not cause adenotonsillar hypertrophy or snoring, and urinalysis would likely show glucosuria. (Choice D) Recurrent urinary tract infections can cause secondary enuresis and are a risk factor for pyelonephritis. However, patients typically also have daytime symptoms, and urinalysis would likely show leukocyte esterase, nitrites, pyuria, and/or bacteriuria. Educational objective: Obstructive sleep apnea in children can present with secondary enuresis. Severe cases can result in cardiovascular complications. References: Left ventricular hypertrophy and abnormal ventricular geometry in children and adolescents with obstructive sleep apnea. (http://www.ncbi.nlm.nih.gov/pubmed/12016102) Childhood obstructive sleep apnea: one or two distinct disease entities? (http://www.ncbi.nlm.nih.gov/pubmed/18769509) Left ventricular function in children with sleep-disordered breathing. (http://www.ncbi.nlm.nih.gov/pubmed/15757619)

An 8-Year-Old Girl Is Brought to the Office Due to Enuresis