Severe acute kidney injury in a 3-year-old boy with fever and pleural effusion: Answers
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CLINICAL QUIZ
Severe acute kidney injury in a 3-year-old boy with fever and pleural effusion: Answers Aakash Chandran Chidambaram 1 & Sriram Krishnamurthy 1 & Bobbity Deepthi 1 & Pediredla Karunakar 1 & Kaushik Maulik 1 & Sreeram Chandra Murthy Peela 2 & Sujatha Sistla 2 & Sree Rekha Jinkala 3 Received: 14 April 2020 / Accepted: 22 April 2020 # IPNA 2020
Keywords Pneumococcus . Hemolytic uremic syndrome . Microangiopathy . Plasma exchange . Complement
Answers 1. Our patient presented with fever and pleural effusion and developed acute kidney injury (AKI) during the hospital stay. Bacterial infections (e.g., Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, etc.), dengue, leptospirosis, rickettsial infections, and influenza A (including H1N1) and B infections can be associated with the development of acute or subacute febrile pleural effusions. All these conditions can be complicated by AKI. Pleural fluid examination in our patient revealed a cell count of 1600 leukocytes/mm3 (predominantly neutrophils). We diagnosed the pneumococcal infection by polymerase chain reaction (PCR). Microbiological examination of the pleural fluid showed gram-positive cocci in pairs which were confirmed to be Streptococcus pneumoniae by polymerase chain reaction (PCR), even though the blood and pleural fluid cultures were negative for any microorganism. We also ruled out infections such as dengue, scrub typhus, leptospirosis, and
This refers to the article that can be found at https://doi.org/10.1007/ s00467-020-04583-7 * Sriram Krishnamurthy [email protected] 1
Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry 605006, India
2
Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
3
Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
influenza (that may cause pleural effusions and a clinical picture resembling thrombotic microangiopathy) by appropriate investigations (i.e., serological tests and nasopharyngeal swab PCR for influenza). Acute kidney injury could occur in a child with bacterial infections (e.g., Staphylococcus aureus, Streptococcus pneumoniae, etc.), dengue, leptospirosis, rickettsial infections, and influenza infection and could be related to infectionrelated glomerulonephritis (IRGN), acute tubular necrosis (ATN), acute tubulointerstitial nephritis (ATIN), or thrombotic microangiopathy (TMA) [1]. Urinalysis in IRGN shows microscopic hematuria, red blood cell casts, and proteinuria. Urinalysis in ATN might reveal granular casts with an absence of active sediment, while urinalysis in ATIN may show microscopic hem aturia and pyuria with or without eosinophiluria. In this child, urinalysis was initially normal, with no RBCs or proteinuria. However, no further urine samples were available for urinalysis as the child continued to be completely anuric. The evolution of microangiopathic hemol
