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Abstract: PO2320

Nephrotic Syndrome Relapse due to Bee Sting in Steroid-Resistant Nephrotic Syndrome

Session Information

Category: Trainee Case Report

  • 1700 Pediatric Nephrology

Authors

  • Whelan, Russell S., Seattle Children's Hospital, Seattle, Washington, United States
  • Gordillo, Roberto, Seattle Children's Hospital, Seattle, Washington, United States
Introduction

Initial and relapsing presentations of nephrotic syndrome are known to be commonly precipitated by acute illness such as upper respiratory infections and urinary tract infections. Rarely, bee stings can cause development of nephrotic syndrome, with reports of relapses secondary to insect stings being even more sparsely reported. Here we report a patient with steroid-resistant nephrotic syndrome who developed a nephrotic flare after being stung by a bee, and the clinical course to achieve remission.

Case Description

A 14 month old unvaccinated male presented with rapid weight gain, swelling and proteinuria, and was diagnosed with nephrotic syndrome, with renal biopsy consistent with minimal change syndrome. An initial 60mg/m2 course of prednisolone failed to achieve remission. Mycophenolate mofetil (MMF) treatment was then initiated, which resulted in rapid remission. Two months after initial remission, patient sustained several bee stings, with initially minimal localized swelling. Several days later he was noted to have edema, proteinuria and weight gain, and was diagnosed with a relapse of his nephrotic syndrome. Spontaneous remission did not occur after 2 weeks of expectant management, and a subsequent increase in dosing of MMF also provided no clinical benefit. The patient ultimately achieved remission with a brief course of glucocorticoids, which was successfully tapered without incident. Patient has since been stably maintained on his prior effective dose of MMF, and has had no relapses since.

Discussion

To our knowledge, this is the first report of bee stings resulting in nephrotic relapse in a patient with steroid-resistant nephrotic syndrome treated with MMF. Notably, administration of glucocorticoids provided rapid resolution of this relapse, despite a prior lack of steroid efficacy in this patient. This case report highlights bee stings as a trigger for nephrotic syndrome relapses in patients. While not a common trigger, the prevalent exposure to bee and insect stings, in both the general and pediatric populations, argues for clinical awareness of this etiology for nephrotic syndrome presentation and relapse. This report also provides clinical insight into the management of nephrotic syndrome relapses caused by bee stings, and suggests the possibility that glucocorticoid use may be generally effective, irrespective of underlying nephrotic syndrome classifcation.