| Abstract|| |
The idiopathic nephrotic syndrome (INS) of childhood is characterized chiefly by a remitting and relapsing course and its striking susceptibility to corticosteroid therapy. We report a case of relapsing nephrotic syndrome associated with urinary tract infection (UTI) treated with pefloxacin, which is a fluoro-quinolone derivative, in a dose of 800 mg per day. Steroids were avoided because of associated UTI. The UTI responded well and proteinuria disappeared after ten days of treatment with pefloxacin. However, the patient developed arthralgia involving the ankles, the knees and the neck. At this juncture, the drug was discontinued resulting in complete cessation of the joint pain. Pefloxacin increases the production of interleukin-2, a cytokine whose metabolism is modified during nephrotic syndrome. It has been used earlier in children with INS with equivocal results. The toxicity of quinolones for the joints seems more frequent in children, whose cartilage is immature and several cases have been reported. Studies on a larger number of patients are required before drawing any firm conclusions on the usefulness of pefloxacin in the treatment of INS.
Keywords: Nephrotic syndrome, Pefloxacin, Articular toxicity.
|How to cite this article:|
Diouf B, Djoneidi M, Diallo S, Diop TM, Bao O. Pefloxacin in the Treatment of Childhood Nephrotic Syndrome: A Case Report. Saudi J Kidney Dis Transpl 1996;7:31-3
|How to cite this URL:|
Diouf B, Djoneidi M, Diallo S, Diop TM, Bao O. Pefloxacin in the Treatment of Childhood Nephrotic Syndrome: A Case Report. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Sep 20];7:31-3. Available from: http://www.sjkdt.org/text.asp?1996/7/1/31/39537
| Introduction|| |
The diagnosis of the idiopathic nephritic syndrome (INS), is made after the exclusion of any underlying heredo-familial or multisystem disease and drug or microbial exposure. The relative frequency of the varieties of the primary glomerular lesion observed in INS, differs widely according to the age of the patient. Among patients between the ages of two and six years, the prevalence of minimal change disease (MCD) may be as high as 95%, whereas among adults over the age of 60 years membranous glomeronephritis is seen in 40% of cases  .
Minimal change disease is characterized chiefly by a remitting and relapsing course and its Striking susceptibility to corticosteroid therapy. Corticosteroids are known to impair lymphocyte function and to have a dramatic effect on macrophages and monocytes, causing depletion of their numbers and impairment of their ability to phagocytose and present antigens  . Patients who continue to exhibit frequent relapses despite prolonged or repeated cycles of steroid therapy constitute a difficult problem.
Pefloxacin is a fluoro-quinolone derivative and has been reported to be beneficial in inducing remission of steroid resistant INS  . Subsequent reports however, did not support this observation  . We report a case of relapsing nephrotic syndrome associated with urinary tract infection (UTI) treated with pefloxacin.
| Case Presentation|| |
T.R., a 14 year old Pakistani boy living in Senegal for two years, had developed a relapsing nephrotic syndrome at the age of five years, which responded to steroids. The last relapse occurred in October 1993, and remission was obtained after four weeks full dose steroid therapy which was then tapered off progressively. In October 1994, the patient presented with pefloxacin sensitive Staphylococcus aureus UTI and a 4.4 gm/24 hours proteinuria without hypoalbuminemia, associated with a weight gain of 2 kg. Pefloxacin treatment was started at a dosage of 400 mg 12 hourly. On the fourth day of treatment, the patient developed arthralgia, first in the ankles then in the knees and the neck. The symptoms worsened progressively and on day eleven, the patient had a moderate effusion of both knees with pain and limitation of flexion, and the ankles were tender. There were no biological markers of inflammation (complete blood count, erythrocyte sedimentation rate, C-reactive protein). Anti streptolysin O titer, the latex and Waaler-Rose tests as well as the C3 component of complement were normal, and anti-nuclear antibodies were not detected in the serum. Radiograms of the ankles and the knees were normal. Examination of the urine at this juncture revealed that the UTI had disappeared and proteinuria was down to normal limits.
Pefloxacin was replaced with a different class antibiotic, and a progressive and complete cessation of the arthralgia was noted, so that in the next two weeks, all articular signs and symptoms disappeared.
| Discussion|| |
The effectiveness of pefloxacin in the treatment of nephrotic syndrome is yet to be proven, although it increases the production of interleukin-2  , a cytokine whose metabolism is modified during a relapse of nephrotic syndrome  . It is difficult to explain the reason for the disappearance of proteinuria in our case, as urinary infection may by itself cause a mild transient proteinuria. However, the high amount of the proteinuria and the weight gain noted in our patient, suggest the beginning of a relapse. From this point of view, we can assume that pefloxacin has been useful in inducing a remission.
Our patient developed arthralgia which subsided with discontinuation of pefloxacin. More than 20 cases of tendonitis have been reported in association with this drug  . Cases of Achilles tendon rupture, arthropathy as well as neurologic side effects have been reported , . The toxicity of quinolones for the joints seems more frequent in children, whose cartilage is immature, as shown by experiments on cultures of immature chondrocytes  and young rats  .
This case suggests that pefloxacin may be useful in the management of patients with steroid resistant INS. The troublesome side effects should always be borne in mind while using this drug. Studies on a large number of patients are needed before one can draw any firm conclusions on the usefulness of pefloxacin in patients with INS.
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Department of Medicine and Nephrology, Le Dantec Hospital, BP 5124, Dakar Fann