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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 1996  |  Volume : 7  |  Issue : 1  |  Page : 31-33
Pefloxacin in the Treatment of Childhood Nephrotic Syndrome: A Case Report


Department of Medicine and Nephrology, Le Dantec Hospital, Dakar, Senegal

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   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 2019 Nov 18];7:31-3. Available from: http://www.sjkdt.org/text.asp?1996/7/1/31/39537

   Introduction Top


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 [1] .

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 [2] . 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 [3] . Subsequent reports however, did not support this observation [4] . We report a case of relapsing nephrotic syndrome associated with urinary tract infection (UTI) treated with pefloxacin.


   Case Presentation Top


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 Scientific Name Search  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 Top


The effectiveness of pefloxacin in the treatment of nephrotic syndrome is yet to be proven, although it increases the production of interleukin-2 [5] , a cytokine whose metabolism is modified during a relapse of nephrotic syndrome [6] . 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 [7] . Cases of Achilles tendon rupture, arthropa­thy as well as neurologic side effects have been reported [8],[9] . 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 [10] and young rats [11] .

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.

 
   References Top

1.Glassook, Alder, Ward, Cohen. Primary glomerular diseases. The kidney, Brenner, 4th edition 1991;1222-1231.  Back to cited text no. 1    
2.George A, Kaysen. Nephrotic syndrome. Current therapy in nephrology and hypertension 1992;238.  Back to cited text no. 2    
3.Pruna A, Metivier F, Akposso K, et al. Pefloxacin as first-line treatment in nephrotic syndrome (letter). Lancet 1992;340:728-9.  Back to cited text no. 3    
4.Greffriaud-Ricouard C, Jungers P, Chauveau D, Grunfeld JP. Inefficacy and toxicity of pefloxacin in focal and segmental glomerulosclerosis with steroid­resistant nephrotic syndrome (letter). Lancet 1993;341:1475.  Back to cited text no. 4    
5.Riesbeck K, Andersson J, Gullberg M, Forsgren A. Fluorinated 4-quinolones induce hyperproduction of interleukin 2. Proc Natl Acad Sci USA 1989;86:2809-­13.  Back to cited text no. 5    
6.Hinoshita F, Noma T, Tomura S, Shiigai T, Yata J. Decreased production and responsiveness of Interleukin 2 in lymphocytes of patients with nephrotic syndrome. Nephron 1990;54:122-6.  Back to cited text no. 6    
7.Dekens-Konter JA, Knol A, Olsson S, Meyboom RH, de-Koning GH. Tendonitis of the Achilles tendon caused by pefloxacin and other fluoroquinolone derivatives. Ned Tijdschr Geneeskd 1994;138(10):528-31.  Back to cited text no. 7    
8.Jorgensen C, Anaya JM, Didry C, et al. Arthro-pathy with achilles tendon involvement induced by pefloxacin. A propose of a case. Rev Rhum Mai Osteoartic 1991;58(9):623-5.  Back to cited text no. 8    
9.Andrejak M, Schmit JL, Tondriaux A, Hary L, Debailleux S, Moore N. Neurologic side effects of fluoroquinolones. A propose of 9 cases concerning pefloxacin. Therapie 1992;47(5):415-8.  Back to cited text no. 9    
10.Thuong-Guyot M, Domarle O, Pooidalo JJ, Hayem G. Effects of fluoroquinolones on cultured articular chondrocytes flow cytometric analysis of free radical production. J Pharmacol Exp Ther 1994;271(3):1544-9.  Back to cited text no. 10    
11.Hayem G, Petit PX, Levacher M, Gaudin C, Kahn MF, Pocidalo JJ. Cytofluorometric analysis of chondrotoxicity of fluoroquinolone antimicrobial agents. Antimicrob Agents Chemother 1994;38(2):243-7.  Back to cited text no. 11    

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Correspondence Address:
Boucar Diouf
Department of Medicine and Nephrology, Le Dantec Hospital, BP 5124, Dakar Fann
Senegal
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PMID: 18417914

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    Abstract
    Introduction
    Case Presentation
    Discussion
    References
 

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