Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2015  |  Volume : 26  |  Issue : 6  |  Page : 1270--1273

Meningitis and intracranial bleed in a child with steroid-resistant nephrotic syndrome


Kanika Kapoor1, Abhijeet Saha1, Dhwanee Thakkar1, NK Dubey1, Kavita Vani2,  
1 Division of Pediatric Nephrology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Radiology, Postgraduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India

Correspondence Address:
Abhijeet Saha
Division of Pediatric Nephrology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi
India

Abstract

Meningitis and associated intracranial bleeding have been rarely reported in patients with steroid-resistant nephrotic syndrome. We present such a case with raised intracranial tension in a 13-year-old child and discuss the management issues. Prompt recognition and appropriate treatment of these complications can be life saving in a child with nephrotic syndrome.



How to cite this article:
Kapoor K, Saha A, Thakkar D, Dubey N K, Vani K. Meningitis and intracranial bleed in a child with steroid-resistant nephrotic syndrome.Saudi J Kidney Dis Transpl 2015;26:1270-1273


How to cite this URL:
Kapoor K, Saha A, Thakkar D, Dubey N K, Vani K. Meningitis and intracranial bleed in a child with steroid-resistant nephrotic syndrome. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Aug 17 ];26:1270-1273
Available from: http://www.sjkdt.org/text.asp?2015/26/6/1270/168668


Full Text

 Introduction



Complications of nephrotic syndrome (NS) can be either disease associated or drug related. Disease-associated common complications include infections, thromboembolism, hypovolemic crisis, cardiovascular problems and acute kidney injury (AKI). [1] Meningitis and intracranial bleed are rare complications of NS. [2] We report a child with steroid-resistant nephrotic syndrome (SRNS) with meningitis and intracranial bleed presenting with severe intracranial hypertension. Early detection and appropriate treatment of these complications can be life saving in a child with NS.

 Case Report



A 13-year-old male child presented with complaints of fever, headache and vomiting of eight days' duration. There was no history of difficulty in breathing, focal neurological deficit, seizures or visual disturbance at presentation. The child was a known case of NS having late steroid resistance; however, renal biopsy had not been performed by the attending physician. On examination, he was afebrile, with a pulse rate of 90/min, respiratory rate of 28/min and blood pressure of 120/78 mm Hg (90-95 th centile). On general examination, there was pallor, bilateral ptosis and periorbital puffiness. Anthropometry revealed weight of 22 kg (<3 rd centile), height of 132 cm (<3 rd centile) and head circumference of 52 cm (50-85 th centile). On systemic examination, the Glasgow Coma Scale was 13/15, neck rigidity was present and Kernig's sign was positive. Examination of the cerebrospinal fluid (CSF) revealed 150 cells/mm 3 ; 50% polymorphs, protein 76.6 mg/dL and sugar 41 mg/dL. CSF culture showed growth of Streptococcus pneumoniae sensitive to ceftriaxone and linezolid. Other laboratory investigations were as mentioned in [Table 1]. A diagnosis of SRNS with meningitis and AKI (pRIFLE: injury; eGFR, 45 mL/min/1.73 m 2 ) was made. The child was started on antibiotics, inj. Ceftriaxone and linezolid. On Day 2 of the hospital stay, the child developed severe headache, diplopia, bradycardia and hypertension, all features of raised intracranial tension (ICT). He was started on injection mannitol 5 mL/kg single dose followed by 2 mL/kg 6-hourly for two days. Magnetic resonance imaging (MRI) of the brain revealed two hypodense areas measuring 3 mm × 1 mm in the subependymal zone of the medial aspect of the bilateral occipital horn on gradient echo sequence, suggestive of recovering hemorrhage. MR venography was normal [Figure 1]. The prothrombin time (PT), activated partial thromboplastin time (APTT), platelet count and antiphospholipid antibody levels were normal. The child responded to the treatment given. Renal biopsy was performed before discharge for SRNS, which revealed minimal change disease. A final diagnosis of SRNS with meningitis with intracranial bleed was made. Currently, the child is on cyclosporin along with alternate day prednisolone and has achieved complete remission. Protein C and S levels were normal and repeat imaging of the brain was normal at six months of follow-up.{Figure 1}{Table 1}

 Discussion



Children with NS are more prone to infections. The risk factors for infection include low serum IgG levels due to urinary loss of IgG, abnormal T lymphocyte function and decreased levels of factors B (C3 pro-activator) and D, each a component of the alternative complement pathway, which result in a decreased ability to opsonize encapsulated bacteria such as Streptococcus pneumoniae. [3],[4] In addition, use of steroids and other immunosuppressive medications during relapses further increases the risk of infection. Streptococcus pneumoniae has been reported as the most common cause of primary bacterial peritonitis in children with NS; however, its etiological role in bacterial meningitis in NS has rarely been reported. [1]

Cerebrovascular accidents are the determinants of unfavorable outcome in bacterial meningitis. [5],[6],[7],[8] An impairment of blood flow in cerebral vessels during meningitis has been demonstrated in histopathological studies in which arteritis, thrombophlebitis and cerebral infarcts were detected. [7],[9] Additionally, reports of angiographic changes of cerebral arteries have shown vessel wall irregularities, vasospasm and focal dilatation. [7],[10] In patients with bacterial meningitis, there is activation of coagulation and inhibition of fibrinolysis leading to a shift of hemostatic mechanisms in favor of thrombosis. [11] However, intracranial bleed as a complication of bacterial meningitis in children has rarely been reported. Massive clotting may result in the local depletion of coagulation factors, which together with microvascular damage, vasculitis and cerebral infarction, might lead to cerebral hemorrhage. [12] NS being a hypercoaguable state may further predispose to the aforementioned complication. [13],[14] Mandai et al reported a child with NS who had intracranial bleed, sagittal sinus thrombosis and normal coagulation profiles. [15]

Early detection and proper management can prevent the sequelae of these complications. Intracranial hypertension has been associated with worse outcomes following intracranial bleed. In the setting of increased ICT due to meningitis and intracranial bleed, treatment modalities in a critically ill child are osmotherapy using mannitol with a serum osmolality goal of more than 300 mOsm/kg, controlled hyperventilation to a PaCO 2 of 27-30 mmHg or administration of hypertonic saline with a serum sodium goal of 145-155 mmol/ L. [16],[17],[18] Our patient responded favorably to mannitol and intravenous antibiotics.

In conclusion, meningitis and intracranial bleed are rare complications of NS. Early detection and management of these complications can be life saving.

Conflict of interest: None declared.

References

1Park SJ, Shin JI. Complications of nephrotic syndrome. Korean J Pediatr 2011;54:322-8.
2Ajayan P, Krishnamurthy S, Biswal N, Mandal J. Clinical spectrum and predictive risk factors of major infections in hospitalized children with nephrotic syndrome. Indian Pediatr 2013;50:779-81.
3Kaysen GA. Nonrenal complications of the nephrotic syndrome. Annu Rev Med 1994;45: 201-10.
4Harris RC, Ismail N. Extrarenal complications of the nephrotic syndrome. Am J Kidney Dis 1994;23:477-97.
5De Souza AL, Sztajnbok J, Seguro AC. Cerebellar hemorrhage as an atypical complication of meningococcal meningitis. Int J Infect Dis 2008;12:558-9.
6Van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired bacterial meningitis in adults. N Engl J Med 2006;354: 44-53.
7Pfister HW, Borasio GD, Dirnagl U, Bauer M, Einhäupl KM. Cerebrovascular complications of bacterial meningitis in adults. Neurology 1992;42:1497-504.
8Gironell A, Domingo P, Mancebo J, Coll P, Martí-Vilalta JL. Hemorrhagic stroke as a complication of bacterial meningitis in adults: Report of three cases and review. Clin Infect Dis 1995;21:1488-91.
9Hardman JM, Earle KM. Meningococcal infections: A review of 200 fatal cases. J Neuropathol Exp Neurol 1967;26:119.
10Weisfelt M, de Gans J, van der Poll T, van de Beek D. Pneumococcal meningitis in adults: New approaches to management and prevention. Lancet Neurol 2006;5:332-42.
11Weisfelt M, Determann RM, de Gans J, et al. Procoagulant and fibrinolytic activity in cerebrospinal fluid from adults with bacterial meningitis. J Infect 2007;54:545-50.
12Mook-Kanamori BB, Fritz D, Brouwer MC, van der Ende A, van de Beek D. Intracerebral hemorrhages in adults with community associated bacterial meningitis in adults: Should we reconsider anticoagulant therapy? PLoS One 2012;7:e45271.
13Indian Pediatric Nephrology Group, Indian Academy of Pediatrics, Bagga A, Ali U, Banerjee S, Kanitkar M, et al. Management of steroid sensitive nephrotic syndrome: Revised guidelines. Indian Pediatr 2008;45:203-14.
14Gigante A, Barbano B, Sardo L, et al. Hypercoagulability and nephrotic syndrome. Curr Vasc Pharmacol 2014;12:512-7.
15Mandai K, Tamaki N, Kurata H, Fukada Y, Iijima I, Nakamura H. A case of intracranial hemorrhage following superior sagittal sinus thrombosis associated with nephrotic syndrome. No Shinkei Geka 1997;25:1101-3.
16Naval NS, Nyquist PA, Carhuapoma JR. Advances in the management of spontaneous intracerebral hemorrhage. Crit Care Clin 2007; 22:607-17.
17Diringer MN. Intracerebral hemorrhage: Pathophysiology and management. Crit Care Med 1993;21:1591-603.
18Bhardwaj A, Ulatowski JA. Hypertonic saline solutions in brain injury. Curr Opin Crit Care 2004;10:126-31.