SARS-CoV-2 is responsible for a raging pandemic, most commonly affects the respiratory system. However, multisystem involvement and atypical clinical manifestations are not uncommon. Moreover, little is known about the clinical characteristics of kidney-related complications, including hematuria, proteinuria and AKI. Here, we present a case report of a 11 years old Indian adolescent male presenting with features of nephritic syndrome concurrent with SARS-CoV-2 infection, with no antecedent history of any chronic disease or any similar past history, who eventually recovered after receiving supportive treatment.
Covid 19 pandemic continues to manifest as respiratory illness, more severe in adults than children (<18 years). Children and adolescents with COVID-19 do considerably better than adults, with mortality rates in paediatric patients <1% [1,2]. This age group tend to have less severe disease compared to adults. Most people with the SARS-CoV-2 virus infection possess respiratory symptoms ranging from fever cough sore throat but few of them have also been reported with multi-organ involvement, including gastro-intestinal system, liver, bone marrow and kidney, central nervous system [3-5]. When compared with adults, COVID-19 is less frequent in the pediatric population and typically presents respiratory syndrome [3,6]. Isolated nephrological manifestations in COVID-19 have also been reported: Hematuria in a pediatric case and hematuria and albuminuria in critical patients, suggesting an association of COVID-19 with nephritis glomerular changes [7,8].
Herein we describe a case of SARS-CoV-2 infection with nephritic syndrome in a pediatric patient.
On May 26th 2021, a 11 years old boy resident of District Sirmaur, Himachal Pradesh, India reported in Department of Pediatrics with history of fever for two days and generalized edema. The edema first appeared in periorbital region and progresses to upper and lower limbs and then leads to abdominal distension. There were no co-morbidities and no significant past medical history.
On admission, he was febrile with temperature of 100.1°F had pedal edema, respiratory rate of 20/min, heart rate of 96/ min, BP 140/100 mmHg, maintaining saturation of 95% at room air with mild ascitis, normal vesicular breathing with normal cardiac and neurological examination. He had normal development and anthropometric findings.
Investigation
On admission Hb-12.4 g/dl, TLC count 6700 (lymphocyte count-19%, segmented neutrophils-76%), ESR-10 mm at 1 hour, CRP- <6 mg/l, Feritin 163 ng/ml, serum RF- <8 IU/ml, serum Cr-1.74 mg/dl, serum BUN-63 mg/dl, LFT was normal, LDH 674 (200-450), urine analysis shows 3⁺ protein and full of RBC. Due to raised serum creatinine and gross haematuria and protein on urine analysis, further workup done with possibility of glomerulonephritis. His ASO-221 IU/ml, ANA, ANCA, HBV, HCV, HIV, ds DNA were negative. 24 hour urine protein was 248 mg, in 1400 ml of total urine. RTPCR for Covid was positive.
Management and Hospital Coarse
After admission child was managed as per covid guidelines: On day 2 of admission he developed shortness of breath and tachyponea for which oxygen inhalation was given. Child was initially managed as per covid protocol for moderate disease.
On day 5 of admission child had 1 episode of seizure and transient blurring of vision which remain for 4 to 5 minutes, possibility of microvascular thrombus was kept and started on injection enoxaprin and inj dexamethasone, tab amlodipine, inj phenytoin.
After this child had stable course, remain seizure free and never had any vision problem. Inj phenytoin was stopped after 5 days. Supportive oxygen therapy was given for 15 days. Renal biopsy was planned but was not done as child was in covid isolation ward.
On june 27, the RTPCR for COVID-19 came out to be negative. Urine for protein and RBC was negative, had normal B.P. The patient’s condition improved drastically and was discharged on June, 2021 on tab enalapril.
Follow up
Child was followed up for next 1 year. His urine was protein free and remain normotensive. Tab enalapril was stop gradually after 4 months.
Kidney involvement has been vastly described in the literature with regards to viral infections like influenza. In paediatric population there is atypical clinical manifestations of SARS-CoV-2 infection, like Kawasaki like illness, MISC, nephritic syndrome and early recognition of these manifestations is of utmost importance. SARS-CoV-2 is responsible for causing renal injury by a variety of ways like cytokine storm, immune complex mediated injury, secondary to hypovoluemia, hypoxia and shock [9,10].
It has been suggested that the ACE-2 receptors present in the kidney is responsible for the majority of the effects of SARS-CoV-2 infection. PSGN was also in the differential diagnosis but was ruled out in view of insignificant ASO titres [11]. Till date only few cases have been reported of renal system involvement triggered by COVID-19. As covid 19 and streptococcal infection both has similar respiratory complaints and streptococcal infection are ignored during COVID 19 infection. Already known that streptococcal infection has devastating effect on cardiac as well as renal system if not received primary prevention.
In summary, patient was admitted with complaints of fever, eventually developing features of nephritic syndrome, tested positive for COVID-19, who then recovered after receiving supportive treatment. The patient had no significant past history of any renal disease or any chronic illness. Knowing about these manifestations can help Pediatricians all over the world to be aware about the clinical spectrum of the COVID-19 infection.
Acknowledgment
Thank you to Dr. Hitender for his guidance and review of the manuscript
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