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A 5-year-old boy was referred for evaluation of “white-colored, milky urine.” The boy’s mother reported 10 to 12 episodes of white-colored urine occurring during the previous 18 months. She described finding drops of the white-colored urine dried on his underwear that appeared white and crusty, like “dried Maalox.” The boy was otherwise healthy, with no significant past medical history or family history.
A physical examination was entirely unremarkable. Initial laboratory examination of blood and urine, including electrolytes, blood urea nitrogen, creatinine, parathyroid hormone, vitamin D studies, alkaline phosphatase, and urine protein, was unremarkable aside from an elevated urinary calcium-to-creatinine ratio of 0.36 mg/mg. His urine stain with Sudan was negative for fat, ruling out chyluria. The urine was initially cloudy (Figure, A). After the urine was allowed to sit for 30 minutes, a precipitate settled at the bottom of the sample that was cleared after acidification with hydrochloric acid (Figure, B and C). Renal ultrasonography was unremarkable. A 24-hour urine collection revealed hypercalciuria, as well as elevated supersaturations of calcium phosphate and calcium oxalate. A pellet from the patient’s spun-down urine was found to be 80% brushite and 20% basic calcium phosphate.
The evaluation of albinuria has been described in the literature, but this is the first reported description of cloudy white urine due to mineral precipitation in a child. White urine is most often secondary to chyluria, which results from an aberrant communication between the urinary tract and lymphatic system, commonly due to filariasis.
it rarely presents as a white, powdery precipitate in children.
Given that our patient was asymptomatic, we recommended conservative treatment to minimize his calciuria and mineral supersaturation, consisting of a low-sodium diet with no other restrictions, as well as a water intake of 1 to 1.5 L/day.