A 10-year-old female came to the inpatient floor with suspected spontaneous bacterial peritonitis. She had steroid responsive nephrotic syndrome that was intermittent (2 previous episodes). Over the past 2-3 weeks she had been having more fatigue, shortness of breath and for the last 3 days has had periorbital edema with her urine being > 3+ on urine dipstick. She re-started her prednisone 3 days ago. She began having mild abdominal pain last evening and this morning it was increased and was accompanied by nausea and emesis. The past medical history showed her last episode of nephrotic syndrome was 10 months ago. The review of systems was negative.
The pertinent physical exam showed a mildly ill-appearing female who was afebrile, blood pressure of 122/70, pulse of 100, respiratory rate of 24. Her weight was 21 kilograms up from a normal weight of 18.9 kilograms (75%). Her height was 75%. HEENT showed mild periorbital edema. Extremities appeared slightly puffy. Heart showed normal S1, S2 with no murmur. Abdomen was distended with generalized guarding. A small fluid wave was elicited, but no masses were palpable. The rest of the examination was normal.
The laboratory evaluation included a hemoglobin of 13.4 mg/dl and platelets of 432 x 1000/mm2 and white blood count of 15.6 x 1000/mm2, with 79% neutrophils. Her electrolytes were normal with a blood urea nitrogen of 7.0 mg/dl, creatinine of 0.4 mg/dl, total protein of 3.9 g/dl, albumin of 1.030, 1+ glucose and hyaline casts. The radiologic evaluation of a computed tomography examination of the abdomen was negative aside from the presence of ascites. An paracentesis was performed, and it and a blood culture eventually grew S. pneumoniae, confirming the diagnosis of spontaneous bacterial peritonitis. The patient’s clinical course showed her started on vancomycin and ceftriaxone initially and once sensitivities were known she continued on ceftriaxone for a total of 10 days of antibiotics. She received influenza vaccine in the hospital and was discharged home on prednisone to follow up in one month.
Nephrotic syndrome is a common pediatric kidney disease affecting 16 in 100,000 children that leads to proteinuria, hypoalbuminemia, hyperlipidemia and edema. The cause is usually minimal change nephrotic syndrome (77%), focal segmental glomerulosclerosis (8%), membranoproliferative glomerulonephritis (6%) and other causes (9%).
Response to steroid therapy with normalization of urine protein levels by 8 weeks of treatment has good sensitivity and specificity of predicting minimal change nephrotic syndrome.
The nephrotic syndrome initial evaluation is recommended to include:
- All patients
- Urine – urinalysis, urine protein/creatinine ratio (first morning)
- Serum – electrolytes, blood urea nitrogen, creatinine, glucose, albumin, cholesterol level, complement 3 level, purified protein derivative level
- Some patients
- Age > 10 years or with signs of Systemic Lupus Erythematosus – antinuclear antibody level
- Age > 12 years – kidney biopsy
- High risk populations – Hepatitis B and C levels and HIV
Prednisone is recommended for initial treatment of nephrotic syndrome. Prednisone 2 mg/kg/day for 6 weeks (with a maximum of 60 mg) and then prednisone 1.5 mg/kg every other day for another 6 weeks (with a maximum of 40 mg). Then discontinuation of prednisone is recommended.
Because of the complication risks, inactivated influenza and conjugated pneumococcal vaccines are recommended for all patients. Influenza vaccine is recommended for all household contacts too. Live vaccines are deferred until specific criteria are met, however varicella should be given in certain circumstances.
Spontaneous bacterial peritonitis (SBP) is a common complication associated with ascites due to various causes including nephrotic syndrome and cirrhosis. Low albumin and low complement levels are associated with SBP. In children with relapsing nephrotic syndrome the incidence is 5-17.3%.
Signs and symptoms of SBP can include any constellation of the following:
- Abdominal pain and guarding
- Abdominal distension
- Poor feeding
There are no reliable signs/symptoms that indicate a definitive diagnosis other than peritoneal fluid culture.
Streptococcus pneumonia is the most common organism causing SBP. Gram-negative organisms can also cause a significant amount of SBP depending on the population. One review recommends initial treatment with broad-spectrum antibiotics (Cefotaximine in particular) until culture sensitivity and specificity are known. The American Academy of Pediatrics’ RedBook® recommends that for “critically ill infants and children with invasive infections potentially attributable to S pneumoniae, vancomycin in addition to usual antimicrobial therapy (such as ampicillin, ampicillin-sulbactam, cefotaxime, or ceftriaxone) may be considered for strains that possibly are nonsusceptible to penicillin, cefotaxime or ceftriaxone.”
Questions for Further Discussion
1. What is in the differential diagnosis of ascites?
2. What are other common complications of nephrotic syndrome?
3. How common is peritonitis in patients treated with peritoneal dialysis?
- Disease: Spontaneous Bacterial Peritonitis | Nephrotic Syndrome | Kidney Diseases
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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Cavagnaro F, Lagomarsino E. Peritonitis as a risk factor of acute renal failure in nephrotic children. Pediatr Nephrol. 2000 Dec;15(3-4):248-51.
Leonis MA, Balistreri WF. Evaluation and management of end-stage liver disease in children. Gastroenterology. 2008 May;134(6):1741-51.
American Academy of Pediatrics. Pneumococcal Infections, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;529.
Gipson DS, Massengill SF, Yao L, Nagaraj S, Smoyer WE, Mahan JD, Wigfall D, Miles P, Powell L, Lin JJ, Trachtman H, Greenbaum LA. Management of childhood onset nephrotic syndrome. Pediatrics. 2009 Aug;124(2):747-57.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital