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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2014  |  Volume : 25  |  Issue : 3  |  Page : 670-671
Focal segmental glomerulosclerosis associated with psoriasis


Sardar Vallav Bhai Patel Post Graduate Institute of Pediatrics (SVPPGIP), Cuttack, Odisha

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Date of Web Publication9-May-2014
 

How to cite this article:
Pradhan SK, Beriha SS. Focal segmental glomerulosclerosis associated with psoriasis. Saudi J Kidney Dis Transpl 2014;25:670-1

How to cite this URL:
Pradhan SK, Beriha SS. Focal segmental glomerulosclerosis associated with psoriasis. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Nov 14];25:670-1. Available from: http://www.sjkdt.org/text.asp?2014/25/3/670/132234
To the Editor ,

Psoriasis is a chronic papulosquamous inflammatory skin disorder affecting all age groups, [1] occasionally associated with hypertension, diabetes mellitus, rheumatoid arthritis and inflammatory bowel disease. [2],[3] Rarely, it may be complicated by the different types of glomerular involvements such as IgA nephropathy, membranous nephropathy, AA amylodidosis, minimal change disease and, rarely, focal segmental glomeruloscelerosis (FSGS). [4] However, this complication is rarely reported in children. We describe a child with FSGS that occurred simultaneously with psoriasis, an association that has not been previously recognized in a child less than two years age to the best of our knowledge.

A 20-month-old boy was referred for evaluation of steroid-resistant nephrotic syndrome (SRNS). He had already received more than four weeks of daily dose of oral prednisolone, 2 mg/kg/day, and oral diuretics for control of edema. One week later, he developed erythematous scaly lesions over his face, anterior abdominal wall and all extremities. At the time of admission, he had mild edema, cushingoid facies and generalized erythematous skin lesions with exudates [Figure 1]. His blood pressure was 114/76 mm Hg. Investigations showed a hemoglobin level of 11.4 g/dL, total leukocyte count of 8600/mm 2 , total platelet count of 2.2 × 10 6 /mm 2 , blood urea of 22 mg/dL, creatinine of 0.6 mg/dL, albumin of 2.2 g/dL, cholesterol of 340 mg/dL, triglycerides of 76 mg/ dL, ESR of 18 mm/1 st hr, CRP of 0.4 mg/dL, Ca of 7.8 mg/dL and C3 of 96 mg/dL. Urine analysis showed nephrotic range proteinuria (spot protein to creatinine ratio 8.6 mg/mg) and microscopic hematuria. Kidney biopsy showed 26 glomeruli, and two glomeruli had focal segmental sclerosis, while the remaining were within normal limits of morphology [Figure 2]. Basement membrane was not thickened. The tubules showed hyaline cast. The blood vessels were unremarkable. There was medial hypertrophy of arteries accompanied by hyaline arteriosclerosis. The interstitium was mildly edematous with minimal fibrosis on light microscopy. Direct immunofluorescence (IF) was negative for IgG, IgA, IgM, C3c and C1q.
Figure 1: Cushingoid facies and generalized erythematous lesions seen at admission.

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Figure 2: Kidney biopsy showing glomeruli with focal segmental sclerosis.

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FSGS is the most common primary glomerular disorders causing end-stage renal disease. Since the first description of this clinico-pathological entity in the early 1930s, various studies have identified numerous underlying pathogenetic mechanisms. FSGS is still a complex, only partially understood, clinico-pathalogical entity. [5] A number of novel permeability factors that affect human podocyte function have been discovered in human FSGS. [6] Recent research has focused FSGS as a podocytopathy. Critical levels of podocyte stress eventuate in podocyte depletion and glomerular epithelial hyperplasia. The glomerular lesions evolve to form segmental glomerular sclerosis with time. [7]

The occurrence of glomerular disease in psoriasis is rare, and this entity is described as "psoriatic nephropathy." Several glomerular diseases have been identified in a psoriatic patient. Mesangioproliferative glomerulonephritis with IgA deposits, AA amyloidosis and membranous nephropathy are relatively common, but FSGS is a rare association with psoriasis. [8],[9]

Our case of a 20-month-old child with psoriasis had a rare histopathological type of glomerular involvement, namely focal and segmental glomerulosclerosis. The patient responded within six weeks to treatment with cyclosporine A (CsA), oral corticosteroids and ACE inhibitor with complete healing of skin lesion and resolution of edema. The potential pathogenic significance of this rare association between psoriasis and FSGS remains unknown. [10] Whether FSGS and psoriasis might share a similar mechanism of pathogenesis involving cell-mediated injuries needs to be elucidated.

 
   References Top

1.Augustin M, Glaeske G, Radtke MA, Christophers E, Reich K. Epidemiology and comorbidity of Psoriasis in children. Br J Dermatol 2010;162: 633-6.  Back to cited text no. 1
    
2.Dhar S. Banerjee R, Agrawal N, Chatterjee S, Malakar R. Psoriasis in children: An insight. Indian J Dermatol 2011;56:332-45.  Back to cited text no. 2
    
3.Augustin M, Reich K, Glaeske G, Schaefer I, Radtke M. Comorbidity and age-related prevalence of psoraisis: Analysis of health insurance data in Germany. Acta Derm Venereol 2010; 90:147-51.  Back to cited text no. 3
    
4.Bagga A, Menon S, Hari P, Mantan M, Dinda A. Nephrotic syndrome preceding psoriasis in children. Pediatr Nephrol 2007;22:1373-6.  Back to cited text no. 4
    
5.Schell C, Huber TB. New players in the pathogenesis of focal segemental glomerulosclerosis. Nephrol Dial Transplant 2012;27:3406-12.  Back to cited text no. 5
    
6.D'Agati VD. Pathophysiology of focal segmental glomerulosclerosis: New developments. Curr Opin Nephrol Hypertens 2012;21:243-50.  Back to cited text no. 6
    
7.Schwartz MM. The role of podocyte injury in the pathogenesis of focal segemental glomerulosclerosis. Ren Fail 2000;22:663-84.  Back to cited text no. 7
    
8.Ceri M, Kurultak I, Unverdi S, Altay M, Duranay M. An unsual cause of focal segemental glomerulosclerosis: Psoriasis vulgaris. Ren Fail 201l; 32:639-41.  Back to cited text no. 8
    
9.Santra G, Sinha PK, De D. Nephropathy in association with annular psoriasis. J Assoc Physicians India 2011;59:595-7.  Back to cited text no. 9
    
10.Singh NP1, Prakash A, Kubba S, et al. Psoriatic nephropathy-does an entity exist? Ren Fail 2005; 27:123-7.  Back to cited text no. 10
    

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Correspondence Address:
Dr. Subal Kumar Pradhan
Sardar Vallav Bhai Patel Post Graduate Institute of Pediatrics (SVPPGIP), Cuttack, Odisha

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DOI: 10.4103/1319-2442.132234

PMID: 24821176

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