Abstract
COVID-19 infections involving renal diseases are more common in adults
than children, between 36.6% to 40% of hospitalized
patients1 leading to fatal outcomes in 35 to 36% of
cases2. Minimal change nephrotic syndrome (NS) is
commonly associated with the pediatric population. However, there is
limited literature concerning the association between concurrent NS and
COVID-19 infection.
We present the case of a previously healthy 2 year old Caucasian male
who was referred for admission in August 2022 due to worsening new onset
periorbital edema, abdominal distention, and bilateral edema of the
extremities. History showed initial symptoms of intermittent low-grade
fever followed by right eye swelling. He was initially treated for
cellulitis with no improvement. The patient on follow-up tested positive
for COVID-19 infection two days before getting admitted. Due to the
persistence of symptoms and progression of swelling from facial swelling
to abdominal distention and pitting edema of the extremities, he was
referred for admission.
The workup done showed findings consistent with nephrotic syndrome
including edema, nephrotic range proteinuria, hypoalbuminemia, and
hyperlipidemia. The patient responded well to steroid and diuretic
treatment. No complications were noted associated with
hypercoagulability, spontaneous bacterial peritonitis, or the
development of end-stage renal disease. The patient achieved complete
remission within one week of treatment and continues to do so on
follow-up with Pediatric Nephrology service.
This report highlights a unique case of nephrotic syndrome in a child
with a concurrent COVID-19 infection.
Keywords: pediatric nephrotic syndrome, nephrotic range
proteinuria, Covid-19, steroid treatment
Introduction :
The spread of the COVID-19 infection is one of the most significant
pandemics of the twenty-first century. It has and continues to pose an
enormous burden on the United States healthcare system, with over
99,705,095 total accumulated cases3. It exhausted
tremendous resources resulting in bed shortage, staff burnout, inability
to perform elective surgical cases, inadequate health maintenance, and
most importantly, an estimated 921,000 deaths mainly among the
adults3. Children have continued to show lower risk of
infection when compared to adults. As of December 8, 2022, there were
only 18% of the total cases reported4, 3.55% that
required hospitalization4, and only 0.9 deaths per
100,000 cases among children 0 to 17 years of age5. In
both populations, COVID-19 manifests predominantly with respiratory
symptoms such as cough (38.5%) and dyspnea (26.1%)6together with fever (81.2%)7.
Among children, the infection has been less severe and can present with
some unusual manifestations such as urticaria, erythema multiforme,
varicella like eruptions, Kawasaki like picture, and the development of
multisystem inflammatory syndrome (MIS-C)8. There has
also been increasing literature on COVID-19 and the development of
multiorgan dysfunction involving the cardiovascular, central nervous
system, gastrointestinal tract, and the kidneys. Strong predictors of
renal injury are patient comorbidities like hypertension, diabetes,
chronic kidney disease (CKD), chronic obstructive pulmonary disease
(COPD), and malignancy but are more common in adults2.
Kidney involvement, however, occurs in only 10-15% among
children9 and ranges from mild proteinuria and
hematuria to acute kidney injury leading to renal failure and the need
for renal replacement therapy.
A few cases have resulted in nephrotic range proteinuria in the setting
of a concurrent COVID-19 infection. Currently, there are only three
cases reported previously. The first is on an 8 year old boy who
presented with bilateral eyelid and facial swelling a week before he
tested positive for COVID-19. He was asymptomatic except for
gastrointestinal symptom of diarrhea10. The second is
a 15 year old boy who presented with fever, anasarca, myalgia, and
oliguria. Work up was positive for COVID-19 and nephrotic range
proteinuria consistent with nephrotic syndrome11. The
third case is a 5 year old with a presentation similar to the first
starting with periorbital edema and asymptomatic COVID-19
infection12. All three cases showed no prior history
of renal disease raising the possibility of an association between NS
and COVID-19 as a possible viral trigger.
Some of the other viruses associated with glomerulopathy include
respiratory syncytial virus, influenza, parainfluenza, adenovirus,
varicella, and cytomegalovirus. Dossier et al. (2014) noted a
significant prevalence of herpesviruses (EBV and HHV-7) infection or
reactivation in pediatric patients at onset of NS compared to a
control13.
This report is only the fourth case of new onset NS associated with
COVID-19 infection out of 17,946,927 total reported
cases4 among children.