1Senior Resident, Department of Pediatrics, Sgt Medical College, Hospital & Research Institute, Budhera, Gurugram, Haryana, India.
2Postgraduate Student, Department of Pediatrics, Sgt Medical College, Hospital & Research Institute, Budhera, Gurugram, Haryana, India.
3Head of the Department and Professor, Department of Pediatrics, Sgt Medical College, Hospital & Research Institute, Budhera, Gurugram, Haryana, India.
4Assistant professor, Department of Pediatrics, Sgt Medical College, Hospital & Research Institute, Budhera, Gurugram, Haryana, India.
5Professor, Department of Pediatrics, Sgt Medical College, Hospital & Research Institute, Budhera, Gurugram, Haryana, India.
*Corresponding Author : Reena Kumari
Department of Pediatrics, Sgt Medical College, Hospital & Research Institute, Budhera, Gurugram, Haryana, India.
Email: [email protected]
Received : Jun 29, 2022
Accepted : Jul 25, 2022
Published : Aug 01, 2022
Archived : www.jcimcr.org
Copyright : © Kumari R (2022).
Dengue infection is endemic in India and can be associated with other illnesses like nephrotic syndrome . Dengue and nephrotic syndrome share a common spectrum of presentation of plasma leakage leading to proteinemia and hypoalbuminemia further manifesting in form of generalized edema, pleural effusion, and ascites . Hence, dengue infection features may mimic nephrotic syndrome in clinical practice and vice versa. Therefore nephrotic syndrome features may be masked and interpreted clinically entirely as dengue infection in the endemic area at peak season . We report a case of nephrotic syndrome complicated by severe dengue infection and pediatric Multisystemic Inflammatory Syndrome (MIS-C).
Dengue fever ranges from mild febrile illness to severe dengue in form of Dengue Hemorrhagic Fever (DHS) and Dengue Shock Syndrome (DSS) . Expanded Dengue Syndrome (EDS) is a relatively new entity that incorporates a wide range of unusual manifestations of dengue virus infection involving the kidney, liver, heart, and muscle . Though it is a self-limiting disease, there is an increase in morbidity and mortality related to dengue in recent years due to multi-organ involvement.
The covid -19 pandemic represents a multifaceted challenge for health systems across the globe in terms of the clinical spectrum, diagnosis and management as well, when compared with adults, covid -19 is less frequent in the pediatric population and typically presents as respiratory syndrome however, the virus can produce unusual manifestation in children .
A 3½-year-old female child was apparently healthy 8 days back then the child was taken to a private clinic with the complaint of nausea, vomiting, pain abdomen, and abdominal distension, fever, one episode of blood in stools, generalized weakness. The child was admitted for 3 days and investigation showed a normal range Complete Blood Hemogram (CBC), deranged Liver Function Test (LFT) normal urea, creatinine, hypoproteinemia, urine albumin (++), whole abdomen Ultrasonography (usg) suggestive of hepatomegaly with moderate ascites with bilateral pleural effusion. The child was managed with Intravenous (i.v) fluids proton pump inhibitors, ofloxacin, walamycin (colistin sulphate), tablet udiliv (ursodeoxycholic acid), Injection MVI (Multivitamin Injection), injection soda-bicarbonate, injection hepamerz. But in view of nonresolution of symptomatology with persistent oliguria with worsening condition child was referred to a higher center for further evaluation and management. So the Child was brought to our hospital by her parent in very sick condition on the 8th day of illness. The child was having persistent abdominal distension, pain abdomen, nausea, vomiting, decreased urine output, one episode of blood in stool, and generalized weakness. On examination GCS-15/15, severe pallor, icterus, sunken eyes, coated tongue, oral ulcers present, tachycardia, hypotension, low volume feeble pulse with bilateral pitting edema, decreased air entry at bases on auscultation with distended abdomen and hepatomegaly, abdominal girth 50 cm. Initial management was done in PICU (pediatric intensive care unit) on lines of probable dengue with warning signs and started on antibiotics (cefotaxime and azithromycin), iv fluid bolus was given in view of poor urine output followed by injection Lasix, maintenance fluid was continued according to current dengue guidelines, also injection artesunate was given and injection vitamin K in view of blood in the stool. Supportive treatment in the form of laxative, antiemetic, proton pump inhibitor, ursodeoxycholic acid. On further Investigation Dengue Serology (IGM) was positive with a low platelet count of 60000 cell/cm on CBC, covid RTPCR was negative, deranged LFTs, normal urea, creatinine with hyponatremia, and raised acute phase reactant CRP, urine routine and microscopy shown significant pus cells, Also covid antibody titer done which was raised, d dimer was very high and serum ferritin, ESR was also raised, so baby’ was treated on the line of MIS-C, and started on injection methylprednisolone and injection enoxaparin (low molecular weight heparin), intravenous immunoglobulin was also planned but it was refused by father. The patient responded to steroids and there was a resolution of all clinical symptoms. Despite clinical improvement, there was a persistent nephrotic range of proteinuria. After ruling out all secondary causes of nephrotic syndrome, the patient was started on steroid therapy for 6 wks. The patient responded to steroid therapy for a nephrotic range of proteinuria. Lately, steroids tapered off in a period of another 6 wks, and the patient remains asymptomatic.
|Investigations||Outside report||Outside report||Day 8||Day 10||Day 11||Day 13||Day 15||Day 16||Day 23||Day 25||Day 26||Day 27|
|Total leucocyte count/mm3||8400||7600||6000||6300||5200||9400||20,400||21,300|
|serum albumin (mg/dl)||4.2||2.1||2.2||2||2||2.3|
|Urine routine and microscopy||Dark yellow Acidic Albumin ++ Pus cells 8-10/hpf RBC||Yellow Acidic Albumin-nil Pus cells 2-3/hpf||p.yellow acidic albumin-nil pus 1-2/hpf rbc-nil||Alkaline, PH-8.5 p.yellow pus-2-4 cell/hpf rbc-nil||Acidic Albumin +) p.yellow pus 2-3 cell/hpf rbc-nil|
|Blood urea (mg/dl)||38.52||29.60||28 mg/dl||22||10||10|
|Serum sodium (mmol/l)||129||129||139||134||134||135|
|Serum potassium (mmol/l)||5||3.60||4.2||4||4.4||4|
|24- hour urine protein creatinine ratio|
|USG abdomen||Ascites with bilateral pleural effusion, borderline hepatomegaly|
|APTT PTT INR||37.9 sec 13.1 sec 0.9 sec||PT-14.2 sec INR-1||23.5 13.1 1|
|HBS AG||Non -reactive|
|Malaria antigen detection test||Negative|
|Antibodies to Hcv||Non-reactive|
|Dengue IgG Antibody||6.020 panbio negative|
|Dengue IgM||22 panbio Positive|
|Scrub Typhus Antibody||Non reactive|
|Sars-cov-2 total antibody elisa||1.21 positive|
|Covid -19 (Rtpcr)||Negative|
|USG whole abdomen||Acites with bilateral pleural effusion Borline hepatomegaly|
|Urine culture||No growth|
|Blood culture||No growth|
|Echo||Mild pleural effusion|
|Urine culture||No growth|
|Protein/ creatinine Ratio-urine-spot||Protein/creatinine spot-30.7 Creatinine-spot urine-52.617 Protein/creatinine ratio-0.58|
|Urine culture||No growth|
|Total serum cholestrol||214 mg/dl|
|Serum Triglyceriside||230.7 mg/dl|
|25(OH) vit D||46 mg/dl||18.5ng/ml|
New-onset nephrotic syndrome may mimic Dengue infection in clinical practice. Also, new-onset nephrotic syndrome can be triggered by virus illnesses including SARS-COV-2 Virus . So in a country like India where Dengue infection is endemic & in times of covid -19 pandemic, detailed history, thorough clinical examination & appropriate investigations, along with the high index of suspicion, guide the clinician for correct diagnosis & management. The steroid responsiveness seen in the majority of childhood nephrotic syndrome does not to be altered by SARS-covid-2 infection and dengue . More studies are needed to understand the impact & long-term outcome of covid-19 & dengue on new-onset nephrotic syndrome . In the absence of clinical leads, therapeutic guidelines become more apparent as more cases are reported.
New-onset nephrotic syndrome following various viral illnesses has been reported [8-13] our patient, was managed initially on the lines of Dengue Shock syndrome & post covid MIS-C. Our patient responded well to the care and treatment provided & did not have any new-onset clinical symptoms. Lately, even despite the clinical improvement, there was persistent proteinuria in the nephrotic range & then the child started on steroid therapy. Our patient did well & had normalization of proteinuria following corticosteroids. Even though the nephrotic range of proteinuria due to dengue infection, there were no other characteristic features of nephrotic syndrome. Both puffiness around the eye & generalized anasarca can be seen in nephrotic syndrome & dengue infection complicated dengue and nephrotic syndrome can clinically mimic the same with hypoalbuminemia & proteinuria.
The sars-cov-2 virus could be the trigger for a new-onset nephrotic syndrome that shares the same clinical spectrum, capillary leakage as in complicated dengue.