Fatigue among teens can be common. But this high school football player’s case was different. | Medical Mystery
He assumed his malaise was due to dehydration from strenuous exercise in hot weather, but his parents became concerned when his fatigue worsened over weeks
The 16-year-old high school football player had not been feeling well for two weeks.
Summer was coming to an end and in the final hot, humid days of the season, the teen had started preseason training. He guzzled down extra water, assuming his malaise was due to dehydration from strenuous exercise in hot weather.
But his parents became concerned when his fatigue worsened over weeks, and took him to his pediatrician.
Sleep problems, anxiety, eating disorders are common causes of fatigue
The pediatrician questioned whether the boy’s fatigue might be related to obstructive sleep apnea, which is when a person stops breathing transiently during sleep.
Individuals with obstructive sleep apnea are often overweight. The teenager was overweight at 215 pounds, above the 95th percentile for his age. Symptoms of obstructive sleep apnea include snoring, waking up frequently, and fatigue. He denied snoring or interrupted sleep.
The boy’s puffy eyelids made the doctor question whether he was simply tired. The teen said he was still in summer vacation mode: staying up late playing video games and scrolling through social media. But now that he was rising early for preseason practice, he was waking up earlier and getting only 6 hours of sleep.
Teens need 8-10 hours of sleep each night. The doctor talked to the boy and his parents about how much sleep he should get, and with daily reminders from his parents, the boy increased his sleep to 9 hours a night.
As his fatigue persisted, the boy’s parents noticed he was only eating parts of his meals. Restrictive eating can lead to fatigue, and eating disorders can occur in individuals of any weight. The teen said he was eating less because he wasn’t hungry and said he wasn’t experiencing body-image issues.
The doctor asked the boy about his mood, as mental health problems can cause decreased appetite and fatigue. The teen said he was excited about starting high school and denied any anxiety, feelings of depression or suicidal thoughts.
After Labor Day, with football season in full swing, the boy’s symptoms worsened. He felt sluggish all day, never wanted to eat, started to feel nauseated, and his hands and feet were swollen. One day, during warm-up, he developed a headache and shortness of breath. The coach thought he looked unwell and called his parents.
They took him to his doctor, who found his blood pressure to be dangerously high and sent him to the emergency department.
Diagnosis: A rare kidney disease
The teenager did not have dehydration, obstructive sleep apnea, sleep deprivation, an eating disorder, depression, or anxiety. What could be causing his symptoms?
In the emergency department, the triage nurse’s blood pressure measurement was 164/110 — well above the top normal blood pressure for a teenager of 120/80. The teen was whisked back to a treatment room.
Medical staff in the emergency department took blood and urine samples for testing. The tests showed that he was anemic, which is a decrease in the amount of hemoglobin in the blood. The key test to his diagnosis was the urinalysis: he had blood and excessive protein in his urine. The abnormal lab tests combined with his dangerously high blood pressure indicated kidney disease.
A kidney doctor, called a nephrologist, immediately started the boy on medication to lower his blood pressure.
Additional testing showed that he had significant kidney injury. Signs of kidney injury include fatigue, anemia, decreased appetite, blood pressure changes, blood in urine or frothy urine (due to abundance of protein), swelling of the hands and feet, and puffy eyes.
A kidney biopsy revealed a disease known as focal segmental glomerulosclerosis (FSGS), which causes scarring of the glomeruli, the filters of the kidney. This can cause nephrotic syndrome, resulting in the boy’s elevated blood pressure, fluid overload, and protein in the urine.
The cause of FSGS is largely unknown. The disease occurs in 7 out of 1,000,000 people each year. Though rare, it is the second most common cause of the nephrotic syndrome in children.
FSGS is not curable, but treatment can slow the progression of the disease. Treatments include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor blockers, antibiotics, diuretics, immunosuppressive drugs, corticosteroids, and plasmapheresis.
Dialysis or a kidney transplant may be necessary. The life expectancy of people with FSGS varies depending on the severity of their disease.
The teenager responded to treatment and his symptoms resolved, though he will need to be closely monitored by his nephrologist.
Our advice
Back to school means back to hectic schedules for many families. Make time to check in with your teens and ask them how they’re feeling. Even if your teenagers have common symptoms, if they don’t go away or get worse, it’s time to check in with their doctor.
Checkups are also important. Make sure your teens get yearly checkups.
Iswarya Manivannan is a medical student at the Sidney Kimmel Medical College and Rima Himelstein is an adolescent medicine physician at Nemours Children’s Health, Delaware.