Introduction:
Nephrotic Syndrome (NS) is a common renal disease in pediatric ageand most (90%) with NS have a form of idiopathic NS (INS). 85% of
INS is minimal change disease (MCD) and more than 95% MCD wellrespond to steroid therapy1,2. INS is a chronic relapsing disease3.
Relapse incidence of the NS is 60-90% with frequent relapse on 50-60% patients4,5,6. Various factors might contribute to the relapse to
the relapse of the disease4,7. Among them infection might be one ofthe most common factors causing relapse of the NS in children8. So,
this study was carried out to find out the type of infection as a causalfactor for relapsing NS in children.
Methodology
A prospective observational study was done for a period of oneyear and randomly relapsing cases of NS were included in this study.
Children of 1-12 years of age that had previous diagnosis of NS admittedin the pediatric unit with relapse of the disease were included in this
study. The diagnosis was made according to the criteria if InternationalStudy of Kidney Disease (ISKDC) in children. After inclusion of these
cases thorough history and clinical examination were done to findout the associated infection in these cases. History and examination
included cough, fever, chest infection, burning micturition, any foci ofskin infection. These were recorded on the preformed questionnaire.
Every case had total white blood cell with differential count, routineurine analysis and X-ray chest (posterior/anterior) P/A view. Number
of cases and the type of infection was marked in relapsing NS and theresults are compiled statistically.
Results
Total 52 cases of relapsing NS were enrolled in this study. Mean ageof the cases are 6.3 years. Total 40 (76.9%) were male and 12(23.1%)
female. Male /female ratio was 3.3:1. 44(84.6%) children were of poorand rest from middle socioeconomic family. Family history of the
disease was marked in 2(3.8%) cases. Clinical features like cough, fever,chest pain, burning micturition and skin infection depicted in table 1.
Total leucocyte count (TLC) was minimum of 4600/cu mm and maximum15150/cu mm. Neutrophil was minimum of 40% and maximum of 84%.
High TLC was found in 16 (30.8%) out of 52 cases. Other reports wereshown in table II. Relapsing NS cases in children had respiratory tract
infection (RTI) in 14 (26.9%), urinary tract infection (UTI) in 10 (19.2%),Skin infection 2(3.8%) and combined infection in 12 (23.1%). But total
RTI, UTI, combined infection and skin infection was found in 23(44.2%),22(42.3%), 12(23%) and 4(7.7%) of relapsing NS respectively. Total 38
(73.1%) out of 52 relapsing NS was associated with infection and 14(26.9%) had no infection (Table III). Combined infection means the
cases had more than one type of infection together (RTI + UTI, UTI +Skin infection, RTI + Skin infection). Over all 23 (44.2%) had respiratory
tract infection in this study as number of RTI, UTI, Skin infection caseswere found in combined infection group also. Upper respiratory tract
infection was observed among 21(40.38%) and lower in 2(3.84%) cases.
Table 1: Digital images, 110x, showing bone implant contact of conventional surgery implant where length of non-mineralized tissue (green line) was extracted from implant perimeter, yellow line.
Table 2: Leucocyte count and its differential observed in cases of relapsing NS.
Table 3: Type and number of infection observed in relapsing NS in children with its statistical significance
Discussion
Male children suffer frequently from NS. Our study observed higherfrequency among male children. Male/ Female ratio was 3.3:1.
Relapses of the NS were found in higher rate among male children.Average age of the children suffered from relapsing NS in this study
was 6.7 years which is also almost similar to other studies that hadmean age of 5.2 years8,9. Majority of our relapsing cases of NS were of
poor socioeconomic status. This might be due to strong susceptibilityof infection among the poor socioeconomic children. This observation
was similar to the study by Sarker MN &et al4. Isolated respiratorytract infection (RTI) was found to be common (26.9%) in relapsing NS.
Some had combined infection (23.1%), UTI in (19.2%), and skin infectionin (3.8%). Among 22 (42.3%) respiratory tract infections, majority had
upper respiratory tract infection (URTI) in this study. This observationof associated RTI in NS was similar to the study by Khemchand
NM et al8. Other studies observed UTI was the common infectionresponsible for the relapse of the disease. Overall infection was the
important factor causing relapse of the NS10,11. Total 38 (73.07%) ofrelapsing NS had associated any form of infection. This infection might
be due to bacterial or viral which might trigger immunologic responsefor the relapse of the disease. Many studies showed the preventive
role of various strategies in children with NS such as of prophylacticantibiotics, immunoglobulin replacement therapy and vaccine
against streptococcal pneumonia, thymosin as immunomodulatingand T cell stimulating agent, use of Chinese medical herb and zincsupplements12-16.
This study did not isolate the pathogen of infection. So, limitation ofthis study is that, it could not explore whether specific virus or bacterial
infection was responsible for the relapse of the disease.Infection is an important factor for relapsing NS. Among the infections,
URTI and UTI is the most important cause of relapsing NS. In everycase of NS care and prompt treatment must be adopted not to suffer
from infection for the prevention of relapsing NS.
