Nephrotic syndrome in Thai children: Nakornping Hospital experience.

Objective: The purposes of this study are to determine the incidence, age of onset, gender, initial presentations, predictive parameters of frequent relapsers/steroid dependence and steroid resistance, results of disease course, growth retardation and complications of long term prednisolone therapy. Methods: A retrospective descriptive study was done in 37 pediatric patients with their first episode of primary nephrotic syndrome admitted at Nakornping Hospital during 1 October 2002 to 30 September 2005. The data in medical records were analyzed by using descriptive statistics. This study used percentage, mean, median and standard deviation for basic data. Statistical analyses were done by Student’s t – test, Fisher’s exact test and Chi-square test for testing of statistically significant differences. Results: The average age of patients was 7.7 years (male 7.7 years, female 7.7 years). The estimated annual incidence of nephrotic syndrome in healthy children in Chiang Mai was at least 3.48 new cases per 100,000 children younger than 15 years of age with the average of treatment period 19.2 months (2-36 months). Initial presentations consisted of generalized edema (86.4%), renal insufficiency (48.6%), fever (37.8%), hypertension (32.4%), gross hematuria (21.65%), and microscopic hematuria (21.6%). Initial therapy consisted of 60 mg/m2/day prednisolone daily for 4 weeks followed by 40 mg/m2 on alternate days for 4 weeks, thereafter decreasing alternate-day therapy every month by 25% over the next 4 months. Thirty-one patients (83.8%) were steroid-responsive, 6 patients (16.2%) were steroid-resistant. Of the 31 initial responders, 4 patients were excluded because of short follow-up period. Of the remaining 27 patients, 16 patients (59.2%) were nonrelapsers, 4 patients (14.85%) were infrequent relapsers, 6 patients (22.2%) were frequent relapsers/steroid dependence and one (3.7%) subsequently became steroid-resistant. The average of initial remission time (protein-free urine) was 16.4 days (15.2 days in nonrelapsers and infrequent relapsers, 21days in frequent relapsers/steroid-dependent patients). The study for predictive parameters predicting the response of steroid therapy found that a group of the frequent relapsers/steroid-dependent and steroid-resistant patients had ascites, pulmonary edema/plural effusion, moderate renal insufficiency (GFR <60 ml/min/1.73m2 ), and gross hematuria more frequent than a group of the nonrelapsers and infrequent relapsers. But mild renal insufficiency (GFR 60-89 ml/min/1.73m2) was found less than the latter group. Only moderate renal insufficiency was statistically different in both groups. Six frequent relapsers/steroid-dependent patients had average occurrence of 2.83 relapses. All had complete remission. Three patients who used cyclophosphamide had longer complete remission than nonuser group (17 months versus 3.6 months). Seven steroid-resistant patients were treated with cyclophosphamide, 2 patients (28.56%) had complete remission for 25 months, the other two patients had complete remission for 1.5 and 3 months, respectively. Three patients were still depended on steroid. BMI and height for age in all patients were normal except one patient with BMI> 25. Conclusion: The increasing average age of first diagnosis of primary NS may indicate that there are more frequent relapsers/steroid-dependent and steroid-resistant patients than the past. The frequent initial presentations are generalized edema, renal insufficiency, hematuria, fever, and hypertension. The initial parameters that can predict the frequent relapsers/steroid dependence and steroid resistance are moderate renal insufficiency, gross hematuria, pulmonary edema/pleural effusion, and ascites. The frequent relapsers/steroid dependence and steroid resistance had more severe degree of renal insufficiency. The longer duration of treatment until the patient’s urine became protein-free may be a predictor of frequent relapsers/steroid dependence. The long regimen of steroid therapy for the initial episode may result in sustained complete remission and reduce frequency of relapses with few complications and growth retardation. The treatment of frequent relapsers/steroid dependence with cyclophosphamide may result in longer complete remission. Failure of cyclophosphamide therapy in steroid resistance indicates a consideration of other drugs. Therefore, this study indicates the benefits of completed information collection which may improve the outcome of treatment and encourage the physicians to study further for more completed outcomes.

Angiostrongylus cantonensis in the cerebrospinal fluid of a female child with eosinophilic meningitis in Thailand.

An 8 month old girl was admitted to Jomthong Hospital with a history of chronic fever for 2 weeks and seizures. 11 living adult Angiostrongylus cantonensis were recovered from the CSF. The patient was referred to Nakornping Hospital on 15 Nov 1999. She had nuchal rigidity but was conscious. The leukocyte count in blood was 10,900 /mm3, 29% eosinophils. The CSF contained 1,400 leukocytes/mm3, 30% eosinophils. The CSF protein content was 85 mg/100 ml. The CSF sugar content was 31 mg/100 ml. The patient was treated symptomatically and with supportive measures, she underwent further 2 lumbar punctures. She showed a steady clinical improvement and was asymptomatic at the time of discharge on 1 Dec 1999.

Urinary tract infection in Thai children.

A retrospective analysis was made of the hospital records of 122 children below 12 years of age who presented at the Dept of Pediatrics, Siriraj Hospital, May 1989 to April 1993 with first episodes of urinary tract infection (UTI). The male to female ratio was 1:1.3. The largest group of patients were under 1 year of age (23%). In young infants signs and symptoms were frequently non-specific. Urinary symptoms, were found in only 18%. Older children had more specific symptoms i.e. pollakiuria (24%), gross hematuria (22.3%) and dysuria (21.3%). Urine culture was done before antibiotics were given in 101 patients (83%) with positive results in 52 (51.5%) of them. E. coli was the most common organism identified (59.6%). Responses to empirical antibiotics were good with parenteral ampicillin (78.6%), gentamicin (83.3%), and ampicillin combined with gentamicin (90.9%). Cotrimoxazole orally was used with a response of 63%. Radiological investigations of the KUB were performed in 54 patients and abnormalities found in 25 (46.3%) in which hydronephrosis was the most common (13 patients). Vesicoureteric reflux (VUR) was found in 7 patients. The highest prevalence of KUB anomalies and VUR was found in the under 1-year-old group. Mean duration of follow up was 7.5 months. Recurrent infection was found in 18 patients, 2 of them were on antibiotics prophylaxis at the time of infection. Hypertension was also noted in 2 patients. The authors suggest that radiologic evaluations should be done in all children with first episodes of UTI, especially if they are younger than one year. Long term follow up is also recommended to prevent recurrent UTI and complications which may lead to permanent renal damage.