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.