Department of Pediatrics, Maimonides Medical Center, 977 48th Street, Brooklyn, NY, 11219, USA.
J Med Case Rep. 2022 Nov 7;16(1):403. doi: 10.1186/s13256-022-03648-5.
Children with nephrotic syndrome are at increased risk of infections, including bacterial peritonitis, pneumonia, and cellulitis. However, bacterial meningitis, a potentially life-threatening complication, has not been highlighted as an infectious complication of nephrotic syndrome in recent reviews. We report a very subtle and unusual presentation of bacterial meningitis in a child with nephrotic syndrome, which without a high index of suspicion, would have been missed.
A 9-year-old African-American male with a history of steroid-dependent nephrotic syndrome presented to the nephrology clinic for routine follow-up. His medications included mycophenolate mofetil and alternate-day steroids. His only complaint was neck pain and stiffness that the mother attributed to muscle tightness relieved by massage. There was no history of fever, vomiting, headache, photophobia, or altered mental status. On physical examination, he was afebrile (99 °F), but had mild periorbital swelling and edema on lower extremities. He appeared ill and exhibited neck rigidity, and demonstrated reflex knee flexion when the neck was bent. Laboratory evaluation revealed leukocytosis, elevated C-reactive protein, hypoalbuminemia, and proteinuria. Cerebrospinal fluid suggested bacterial meningitis. The patient was treated with ceftriaxone and vancomycin. Both cerebrospinal and blood cultures grew Streptococcus pneumoniae; vancomycin was discontinued. The child completed a 2-week course of ceftriaxone and was discharged home.
A high index of suspicion is necessary in children with nephrotic syndrome treated with corticosteroids, as symptoms may be masked, and thus, a life-threatening disease be missed. Bacterial meningitis should be highlighted as a serious infection complication in children with nephrotic syndrome.
患有肾病综合征的儿童感染风险增加，包括细菌性腹膜炎、肺炎和蜂窝织炎。然而，细菌性脑膜炎是一种潜在的危及生命的并发症，在最近的综述中并未被强调为肾病综合征的感染并发症。我们报告了一例肾病综合征儿童中非常微妙和不寻常的细菌性脑膜炎表现，如果没有高度的怀疑，这可能会被遗漏。
一名 9 岁的非裔美国男性，患有类固醇依赖性肾病综合征，因常规随访到肾病科就诊。他的药物包括霉酚酸酯和隔日类固醇。他唯一的抱怨是颈部疼痛和僵硬，母亲认为是肌肉紧张，按摩后可缓解。他没有发热、呕吐、头痛、畏光或精神状态改变的病史。体格检查时，他体温正常（99°F），但有轻度眶周肿胀和下肢水肿。他看起来病了，表现为颈部僵硬，当颈部弯曲时，表现出膝盖反射性弯曲。实验室检查显示白细胞增多、C 反应蛋白升高、低白蛋白血症和蛋白尿。脑脊液提示细菌性脑膜炎。患者接受头孢曲松和万古霉素治疗。脑脊液和血液培养均培养出肺炎链球菌；停用万古霉素。患儿完成了 2 周头孢曲松疗程，出院回家。
接受皮质类固醇治疗的肾病综合征儿童需要高度怀疑，因为症状可能被掩盖，从而可能错过危及生命的疾病。细菌性脑膜炎应被强调为肾病综合征儿童的严重感染并发症。
