Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2004  |  Volume : 15  |  Issue : 4  |  Page : 486--488

Varicella-Induced Remission of Steroid-Resistant Nephrotic Syndrome in a Child


Mohamad Bassam A Saeed 
 Pediatric Nephrology Department, Kidney Hospital, Ibn Alnafis Medical Complex, Damascus, Syria

Correspondence Address:
Mohamad Bassam A Saeed
Kidney Hospital, P.O.Box 8292, Damascus
Syria

Abstract

We report a Syrian boy aged three years and four months, a known case of the nephrotic syndrome (NS) diagnosed 18 months earlier. In view of non-response to steroid therapy administered according to the ISKDC regimen, a kidney biopsy was performed which showed features compatible with minimal change disease. While on alternate-day steroid therapy, he developed a typical rash of very severe varicella. Steroid therapy was stopped and intravenous acyclovir was administered for five days, followed by oral acyclovir. The child made a full recovery from chickenpox which was associated, in addition, with a complete remission of the NS. His remission has been sustained after a follow-up of six months. In conclusion, to the best of our knowledge and following an extended search, this case is the probably first ever published about varicella-induced remission of steroid-non responsive NS.



How to cite this article:
Saeed MA. Varicella-Induced Remission of Steroid-Resistant Nephrotic Syndrome in a Child.Saudi J Kidney Dis Transpl 2004;15:486-488


How to cite this URL:
Saeed MA. Varicella-Induced Remission of Steroid-Resistant Nephrotic Syndrome in a Child. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2020 Feb 21 ];15:486-488
Available from: http://www.sjkdt.org/text.asp?2004/15/4/486/32881


Full Text

 Introduction



It has been repeatedly noticed in the litera­ture that intercurrent measles infection may induce remission of the nephrotic syndrome (NS), which could be explained on the basis that measles infection causes a prolonged depression of cell-mediated immunity thereby inducing a temporary remission of steroid­sensitive NS. [1] We herewith report a child with minimal change NS who had sustained remission of the nephrotic state following an episode of chicken pox.

 Case Presentation



The case is of a previously well, three years and four months old boy, a known case of NS for the last one-and-half years. He did not have a past history of clinical varicella, infe­ction or a history of having received varicella vaccination. Prednisolone therapy was initiated at a daily dose of 60 mg/m², given for four weeks followed by 40 mg/m² given on alter­nate days for the next four weeks. The child remained nephrotic at the end of this treatment schedule with 24-hours urinary protein of over two grams. The child was classified as steroid-non responsive NS and a kidney biopsy was performed before considering further immunosuppressive therapy. Light microscopy findings were consistent with a diagnosis of minimal change disease. Immuno­fluorescence and electronic microscopy were not performed. At this juncture, a course of cyclosporine was contemplated to induce remission. However, a few days after the biopsy and while the child was on alternate­day steroid therapy, he developed a typical rash of an overwhelming varicella after contact with another child who had developed the infection. Steroid therapy was stopped and intravenous acyclovir was administered for five days followed by oral acyclovir for seven days. The infection followed a benign course and gradually disappeared. Interest­ingly, we noticed a gradual disappearance of the edema during the acute phase of chicken pox; urine samples sent on three consecutive days were negative for proteinuria and a 24­hour urine sample confirmed remission of the NS. It is worth mentioning that the child had a 2-gram/24 hours proteinuria just two days before the varicella infection Since then, the child has been on regular follow-up and continues to be well without any medication after six months of follow-up.

 Discussion



Varicella, or chicken pox, is a very common and extremely infectious condition. When the infection develops in a patient on cortico­steroid therapy, it can be associated with significant morbidity. [2] Vaccination against varicella is indicated in patients with the NS who have been in remission for a few months after steroid therapy. [3],[4] The susceptibility of contracting varicella is related, not to lack of past history of varicella, but by low or undete­ctable serum antibody levels. [3],[4]

Measles virus was the first virus reported to alter immune function. Various aspects of immune dysfunction, have been reported following measles infection including reduction of mitogen-induced proliferation of T cells (Similar findings were reported in individuals following vaccination against this virus), modulation of immune system function by measles virus infection, and a possible role of a soluble factor that can inhibit antigen­specific T-cell proliferation and inhibit the proliferation of uninfected B cells. [5]

It has been well known for many years now, that remission of steroid-sensitive NS may be induced by intercurrent measles infection. [1] The mononuclear cell subsets as well as lympho-proliferative responses were studied during the phase of acute measles infection both in remission and relapse of the NS. Both indices, studied in a medium contain­ing autologous serum with complement, were decreased during acute measles infection. There is an increase of OKT8 cells and Leu-7 cells in relapse, and a decrease in remission, of the NS. These factors that occur in natural measles infection jointly cause a prolonged depression of cell-mediated immunity and induce a temporary remission of steroid­sensitive NS.

All these data were studied during and after measles infection; similar data could not be found in the literature in connection with varicella infection and its possible effect as "remission inducer" of NS. To the best of our knowledge and following an extended search, we believe that this case is the first ever published about varicella-induced remission of steroid-non responsive NS.

References

1Lin CY, Hsu HC. Histopathological and immunological studies in spontaneous remission of nephrotic syndrome after intercurrent measles infection. Nephron 1986;42:110-5.
2Resnick J, Schanberger JE. Varicella reacti­vation in nephrotic syndrome treated with cyclophosphamide and adrenal corticoste­roids. J Pediatr 1973;83:451-4.
3Centers for Disease Control and Prevention. Prevention of varicella: recommendation of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep 1996; 45(11): 5-6
4Recommendations for the use of live attenuated varicella vaccine. American Academy of Pediatrics COID: Pediatrics 1995;95:791-6.
5Fujinami RS, Sun X, Howell JM, Jenkin JC, Burns JB. Modulation of immune system function by measles virus infection. Role of soluble factor and direct infection. J Virol 1998;72:9421-7.