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Letters to Editor
22 (
2
); 151-152
doi:
10.4103/0971-4065.97147

Relapse of nephrotic syndrome after a bee sting

Department of Nephrology, Ankara Education and Research Hospital, Ankara, Turkey
Department of Nephrology, Gulhane Military Academy of Medicine, Haydarpasa Training Hospital, Istanbul, Turkey
Address for correspondence: Dr. Mevlut Ceri, Ankara Education and Research Hospital, Department of Nephrology, Cebeci, Ankara, Turkiye. E-mail: mevlutceri@gmail.com
Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

Sir,

Relapses in patients with minimal change disease (MCD) have been rarely reported following exposure of inhaled allergens, foods, insect stings, and vaccination.[1] Herein, we report a case with relapse after a bee sting while in complete remission.

A 28-year-old male presented with sudden onset generalized edema. One week before the admission he had a bee sting on his forearm. He had a known medical history of MCD, but was in complete remission for 6 years. Seven days after the bee sting the patient had marked edema on the face, and legs. On admission the patient was afebrile, with eyelid and 3+ pretibial edema and a normal blood pressure of 110/60 mmHg. Laboratory examinations revealed proteinuria (2708 mg/day), normal renal function (creatinine 0.8 mg/dl), total serum protein 5.1 g/dl, serum albumin 2.8 g/dl, total cholesterol 315 mg/dl, triglycerides 68 mg/dl, LDL cholesterol 228 mg/dl, and white blood cell 19,600/mm3. We accepted these findings and symptoms as a relapse of disease, and methylprednisolone treatment was introduced at the dose of 1 mg/kg/day. One week later his proteinuria resolved to 356 mg/day and clinically improvement was observed. The dosage of corticosteroid was tapered to 4 mg/day over the next 4 weeks, and there was no relapse during 1-year follow-up.

Bee stings usually cause minor local allergic reactions. But, systemic complications such as glomerulonephritis (GN), interstitial nephritis, acute renal failure, myocarditis, centrilobular necrosis of liver, Guillain-Barre syndrome, and vasculitis can be seen.[24] GN is rare and there are little known data about histological findings, long-term follow-up, incidence, and response to therapy of GN after an insect sting. Cuoghi et al., in their series, include 180 children with nephrotic syndrome (NS); found that three children had recurrent NS triggered by the insect sting and the remission was achieved with steroid therapy in all.[3] Although spontaneous remission may occur in some cases, the most reported cases required corticosteroid therapy for remission.[24] Similarly, oral steroid treatment-induced prompt remission in our case.

Recent data suggest that atopic disorders are common in patients with MCD despite of little evidence that they have a direct pathogenic role in this disorder. Many patients with MCD have increased serum immunoglobulin (Ig) E and interleukin (IL)-13 levels. IL-13 has the ability to cause switch from IgM to IgE in B cells and induce CD80 expression by podocytes.[1] It may be responsible for developing proteinuria and increased IgE levels. Reiser et al., showed that induction of CD80 by podocytes results in proteinuria in rat with glomerular epithelial cell foot-process fusion.[5] Morever, urinary CD80 levels increased in patients with MCD during relapse and return to normal after remission.[1] Consequently, recent studies suggest that IL-13 may mediate proteinuria in patients with MCD because of its ability to directly induce CD80 expression on the podocyte.

References

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  5. , , , , , , . Induction of B7-1 in podocytes is associated with nephrotic syndrome. J Clin Invest. 2004;113:1390-7.
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