Nephrotic Syndrome Associated with Varicella

Infection

Ching-Yuang Lin, MD, Hey-Chi Hsu, MD, and Han-Yang Hung, MD

From the Department of Medical Research, Veterans General Hospital; Department of

Pediatrics, Mackay Memorial Hospital; and Department of Pathology, College of Medicine,
National Taiwan University, Taiwan, Republic of China

ABSTRACT. A 4-year-old boy developed nephrotic syn- has been studied histologically.7 In this communi-
drome following varicella infection. Serologic studies dur- cation, we describe a young boy who suffered from
ing the early phase ofthe disease demonstrated a decrease
nephrotic syndrome in association with varicella
in serum C3, C4, and properdin factor B. Renal biopsy
revealed an acute proliferative glomerulonephritis with infection, followed by a complete recovery.
deposition of immunoglobulins and M, C3, Clq,
A (IgA)
and varicella virus antigen in the glomerulus, suggesting
an immune complex deposition. Ultrastructurally, this CASE REPORT
suggested a postinfectious immune complex glomerulo-
nephritis. These phenomena suggested that varicella vi- A 4-year-old boy who was in good health was in contact
rus antigen antibody complexes were deposited in the with patients with varicella approximately 3 weeks prior
glomerulus and activated the classic and alternative path- to his admission to the hospital. He developed fever and
way of complements, leading to an immune complex malaise six days before admission. Three days later, crops
glomerulonephritis. During the nephrotic phase, an in- of small, red papules appeared and immediately devel-
crease in OKT8 cells and decrease of the OKT4 cells oped into clear vesicles on the trunk. At the same time,
were demonstrated. Two months later, this alteration these vesicles spread to the extremities where crusts
returned to normal as the renal disease was in remission.
formed. The vesicles were also found on mucosal surfaces
This change oflymphocyte subsets during varicella infec-
of the mouth and genital area. High fever (up to 39.5#{176}C),
tion may play a role in the pathogenesis of nephrotic
hemorrhages into the vesicles, petechiae and ecchymoses
syndrome. Pediatrics 1985;75:1127-1131; nephrotic syn-
drome, varicella infection, OKT4 cell, OKT8 cell. over the lower extremities, and bloody stool developed.
The boy was admitted to Mackay Memorial Hospital on
May 15, 1983. During initial examination, microscopic
hematuria was noted and two days later puffy face, weight
gain, and generalized edema developed: No history of
A few virus infections have been reported to be drug allergy or previous chickenpox infection was elicited.
associated with histologic abnormalities and dys- Physical examination on admission revealed a moder-
function of the kidney.12 In previous studies, we ately ill-appearing child who was fully conscious. There
demonstrated a strong association of hepatitis B were widely scattered hemorrhagic vesicles with an ery-
surface antigenemia and membranous nephrop- thematous base over the trunk and extremities. Coarse
athy3 and an association of measles and acute gb- breathing sounds without moist rales were audible over
merubonephritis.4 However, renal involvement is both lung fields. Blood pressure was 100/70 mm Hg.

rather uncommon in varicella infection.5 The his- Urinalysis revealed protein (++) and hematuria (50 to
60 RBC per high-power field). Findings from bacterial
tobogic changes include proliferative gbomerubone-
cultures of blood and vesicular fluid were all negative.
phritis as as tubular
well necrosis in sporadic cases
Initial blood studies revealed hemoglobin 12.3 g/dL, hem-
in adults.6 Varicella infection associated with ne-
atocrit value of 36.5%, WBC count of 11,4OO/sL (83%
phrotic syndrome is rare; only one case (in an adult) segment forms of neutrophils, 1% monocytes, 16% lym-
phocytes), and a platelet count of 160,000/sL. Bleeding
time and clotting time were within normal limits. No
Received for April 25, 1984; accepted
publication Oct 15, 1984.
evidence of microangiopathic hemolytic anemia was pres-
Reprint requests (C.-Y.L.) to Pediatric Research Laboratory,
ent. ESR was 25 mm/h. BUN was 79 mg/dL and serum
Department of Medical Research, Veterans General Hospital,
Shih-Pai, Taipei, Taiwan 112, Republic of China. creatinine level was 1.7 mg/dL. The ablumin to globulin
PEDIATRICS (ISSN 0031 4005). Copyright 1985 by the ratio was 1.0:2.5, serum cholesterol level was 235 mg/dL,
American Academy of Pediatrics. serum triglyceride level was 195 mg/dl, and C-reactive

PEDIATRICS Vol. 75 No. 6 June 1985 1127

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 TABLE. Sequential Changes in Urinalyses, Serum Albumin to Globulin (A/G) Ratio,
BUN, Creatinine, Complement Components, and T-Cell Subsets*
Date Urine Serum (mg/dL) T-Cell
Subsets (%)

Protein RBC/HPF A/G BUN Creatinine C3 C4 PFB OKT4 OKT8

(Heat)
5/25/83 ++ 50-60
5/27/83 +++ 2-3 2.0/2.6 79 1.7 36 24 12 27 44
5/30/83 +++ 0 20 45
5/31/83t +++ 35-40
6/7/83 ++ 6-8 2.0/2.6 47 1.1
7/2/83 + 0 12 0.8 21 46
8/2/83 - 0 58 26
10/8/83 ++ 50-70 2.3/2.3 13 0.5 43 41
12/16/83 - 0 110 46 36 45 25
* Abbreviations used are: HPF, high-power field; PFB, properdin factor B. Normal range
of values are: C3, 80 13 mg/dL; C4, 42 9 mg/dl; properdin factor B, 20 6 mg/dl,
OKT4 cells, 40% 8%; OKT8 cells, 26% 5%.
t Biopsy.

protein was 2+; findings for fluorescent antinuclear an- MATERIALS AND METHODS
tibody and hepatitis B surface antigen were negative.
Serology performed on the first and eighth days of hos-
The kidney biopsy was obtained by percutaneous
pitalization and 1 month after admission showed a needle biopsy. The specimen was immediately di-
greater than fourfold increase in varicella virus antibody vided into three portions and processed for light,
titer (increasing from 1:2 to 1:32 to 1:128 of complement immunofluorescence, and electron microscopy as
fixation antibody titer) compatible with a recent varicella described elsewhere.3
infection. Antistreptolysin 0 titer estimation was 12 For immunopathologic examination, 4-tm cryo-
Todd units on admission and 2 weeks later. Serial studies stat sections were air dried, and then incubated
of urinalysis and serum complements were performed; with fluorescein isothiocyanate-conjugated rabbit
results are summarized in the Table. Values for serum
antisera to human IgG, 1gM, IgA, C3, Clq, C4
immunoglobulins were: IgG 864 mg/dL, 1gM 150 mg/dL,
(Behring Werke, West Germany), properdin, and
and IgA 210 mg/dL. Two days after admission to the
fluorescein isothiocyanate-labeled 1gM (Dekopatts,
hospital, the patient developed a puffy face and general-
ized edema. In addition, he had a high fever, microscopic Bio-Rad, Denmark).
hematuria, hemorrhagic vesicles, bloody stool, and azo- The fluorescent antivaricella conjugate was pre-
temia. Because of his critical condition, a regimen of a pared from a pool of human convalescent sera ob-
specific bovine thymic extract (Thymostimulin) in a dos- tamed from a group of people who had recently
age of 1 mg/kg/d, via intramuscular injection was started recovered from varicella infection. This pool of sera
on the third day of hospitalization in addition to symp- had a complement fixation antibody titer greater
tomatic treatment. Three days later, the clinical features than 1:1,000 against varicella virus. After precipi-
markedly improved, but proteinuria (++++) persisted. tation with ammonium sulfate, the globulin fraction
Oral prednisolone at a dosage of 2 mg/kg/d was then
was conjugated with fluorescein isothiocyanate and
added until the boys condition was in remission. Thy-
used for direct staining.4 The cryostat sections of
mostimulin was used for another four days and stopped
kidney tissue were incubated with the antivaricebla
after clinical improvement of the varicella infection. A
renal biopsy was performed on the seventh day of hospi- conjugate for 30 minutes at 37#{176}C. The slides were
talization. During his stay in the hospital, the boys then rinsed three times with phosphate-buffered
condition improved as evidenced by the normalization of saline solution for ten minutes each time, then
serum BUN and creatinine levels and decrease in pro- mounted with buffered glycerine. For electron mi-
teinuria. On day of hospitalization,
the 14th the patient croscopy, the specimen was fixed in 4% glutaral-
was discharged in good health with mild proteinuria. The dehyde buffered with 0.1 M sodium cacodylate, then
prednisolone treatment was changed to alternating days postfixed in osmium tetroxide, and finally embed-
and gradually tapered to a maintenance dosage. Three ded in low-viscosity Spurr medium as described
months later the prednisolone therapy was stopped. The
previously.3 Double-stained ultrathin sections were
boy was regularly followed-up in our outpatient clinic.
examined with a Hitachi HU-11E electron micro-
During the 17 months of follow-up observation, there was
only one episode of upper respiratory tract infection
scope.
associated with microscopic hematuria and proteinuria; Immunochemical determinations of serum C3,
it lasted for three days. Up to the time of this report, the C4, and properdin factor B were performed by
boys renal function, urinalysis, and serum complement commercially available immunoplates (C3 and C4
levels have all remained within normal limits. from Oxford Laboratories, mc, Foster City, CA,

I 128 NEPHROTIC SYNDROME AND VARICELLA INFECTION

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and properdin factor B from Behring, West Ger-
many).
The lymphocytes were isolated by the Ficobl-
Hypaque method and were checked for the active
T cells and total T cells by the E-rosette technique
and B lymphocytes by the EAC-rosette technique
and B lymphocytes by the EAC-rosette method.8
Phenotypic analysis of T-cell subsets was per-
formed using indirect immunofluorescence with
mouse monocbonal antibodies (OKT4, OKT8 anti-
sera, Ortho Pharmaceutical Corp, Raritan, NJ).
The inhibition of macrophage migration was de-
termined by indirect agarose method.9 Using 0.02
mL of specific varicebba antigen, a reduction of 20%
of more in the area of migration constituted a
positive migration inhibition assay.
The determination of circulating immune com- Fig 2. Immunofluorescence stain with fluorescein iso-
plexes was performed by using 3.5% polyethylene thiocyanate-labeled antihuman immunoglobulin A (IgA)
glycol according to the method of Digeon et al.#{176} showing diffuse granular deposition of IgA, predomi-
nantly in mesangial region (x360).

RESULTS

Pathologic Study

The renal biopsy revealed 15 glomeruli on routine

histologic section and showed moderate endocapil-
lary cell proliferation and polymorphonuclear leu-
kocyte and monocyte infiltration resulting in par-
tiab occlusion of gbomerular capillaries. There was
also focal degeneration of the tubular epithelium
and interstitial mononuclear cell infiltration. The
histologic picture was indicative of acute prolifera-
tive gbomerubonephritis (Fig 1).
Immunofluorescent examination demonstrated
moderate amounts of granular deposits of IgA (Fig
2), IgG, and 1gM, and small amounts of C3 and
Clq, mainly in the mesanguim. Staining with the
Fig 3. Immunofluorescence stain with fluorescein iso-
fluorescein isothiocyanate-conjugated convalescent thiocyanate-labeled varicella antibody showing diffuse
mesangial deposition (x300).

sera from patients with varicella also showed a

granular deposition in the glomeruli (Fig 3). Kidney
biopsies from three patients, one with minimal
change nephrotic syndrome, one with poststrepto-
coccal gbomerulonephritis, and one with IgA mes-
angiab proliferative glomerulonephritis were used as
controls; negative results were obtained in these
cases.
Electron microscopic studies showed a moderate
amount of granular electron-dense deposits in the
paramesangial regions (Fig 4). Occasional suben-
dothelial deposits associated with focal derange-
ment of the adjacent glomerular basement and loss
of the foot processes were also seen. However, the
Fig 1. Two glomeruli showing diffuse endocapillary cell
proliferation with occasional leukocyte in capillary lumen foot processes in general were well preserved, as
(hematoxylin-eosin; x600). was the glomerubar basement.

ARTICLES 1129
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 DISCUSSION

In 1884, Henoch1 first described four children

who developed puffy face, edema, hematuria, and
proteinuria three to 1 1 days after the appearance
of varicella vesicles. However, the varicella infec-
tion is infrequently associated with renal compli-
cations. In a large series (2,534 cases) of patients
with varicella infection, only three (0.12%) devel-
oped clinical nephritis.5 Renal lesions occurred
more frequently in fatal cases of varicella infec-
tion.2 The histologic alterations consist of con-
gested, hemorrhagic glomeruli, endothelial hyper-
plasia, and varying degrees of tubular necrosis.6
Krebs and Burvant7 reported a case of nephrotic
syndrome in association with varicella infection,
showing endothelial and epithelial hyperplasia in
the glomeruli. Singhal et al3 reported a case of
rapidly progressive glomerulonephritis associated
with varicella infection in a 12-year-old boy.4 Ho-
sakai et al14 also reported a Japanese girl who had
acute glomerulonephritis with nephrotic syndrome
during the incubation period of varicella infection
with granular deposition of IgG and C3 in the
glomeruli. Electron microscopy demonstrated
hump-like electron-dense deposits in the subepithe-
Fig 4. Part of glomerular tuft (seen using electron mi- hal and subendothelial regions.4 Our patient had a
croscopy) showing mesangial electron-dense deposit (D) full-blown manifestation ofthe nephrotic syndrome
with subendothelial extension (d). Polymorphonuclear
leukocyte (PMN) is seen in lumen (x4,800). which developed after varicella infection. No other
cause of nephrotic syndrome could be elicited. Al-
though IgA was found to be the predominant im-
munoglobulin deposited in the kidney, the histo-
Immunologic Study
logic picture and the presence of Clq distinguish
Studies of cell-mediated immunity were as fol- the present case from IgA nephropathy.5 The re-
lows: active T cell, 25% (normal 46% 8%); total lationship of the development of varicella and the
T cells, 63% (normal 74% 8%); T-cell subset onset of nephrotic syndrome, the healing of van-
analysis using monoclonal antibodies showed: cella and the resolution of nephnotic syndrome, and
OKT3 cells, 64% (normal 74% 10%); OKT4 cells, the immunofluonescent demonstration of vanicella
27% (normal 40% 8%); OKT3 cells, 44% (normal antigen in the glomeruli suggested to us that the
26% 5%); and OKT/OKT8 ratio, 0.61. The serial nephropathy developed after vanicella infection. To
changes of OKT4 cells and OKT8 cells are shown the best of our knowledge, this is the first report to
in the Table; a decrease in OKT4 cells and increase demonstrate the presence of vanicella virus antigen
in OKT8 cell populations were demonstrated. The in the glomerular immune deposits.
serum C3, C4, and properdin factor B levels de- The elevated level of IgG-circulating immune
creased (Table), but returned to normal values 6 complexes and IgA-cinculating immune complexes,
months later. On the third day of hospitalization, and the transient decrease in serum levels of C3,
the IgA-circulating immune complexes level was 18 C4, and properdin factor B were compatible with
g/mL, IgG-circulating immune complexes was 26 an immune complex disease involving both the
tg/mL, but 1gM-circulating immune complexes classic and alternative pathways of complement
were undetectable. Thresholds for positivity were: activation.
IgA, 10.6 tg/mL; IgG, 20 tg/mL, and 1gM, 12.4 g/ Thymostimulin is a specific bovine thymic ex-
mL). All circulating immune complexes were un- tract. The in vitro studies of the effects of thymo-
detectable 1 month later. The macrophage migra- stimulin on mouse lymphocytes can be summarized
tory inhibitory assay indicated that the lympho- as: (1) effect on surface markers and increase of E-
cytes failed to produce migration inhibition factor rosette-forming cells and increase of B cells (EAC),
when cultured with varicella antigen. Six months (2) increasing proliferative response of lymphocytes
later, this function returned to normal. to mitogens, (3) induction of cytotoxicity, (4) en-

1130 NEPHROTIC SYNDROME AND VARICELLA INFECTION

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hancement of interferon production, (5) enhance- 3. Hsu HC, Lin GJ, Chang MH, et al: Association of hepatitis
ment of graft-versus-host disease reaction, lympho- B surface (HBs) antigenemia and membranous nephropathy
in children in Taiwan. Clin Nephrol 1983;20:121
poiesis, delayed-type hypersensitivity skin test and 4. Lin C-Y, Hsu H-C: Measles and acute glomerulonephritis.
antiviral activity and, (6) antitumoral activity.6 In Pediatrics 1983;71:398
5. Bullowa JGM, Wishik SM: Complications of varicella. Am
the laboratories of Istituto Farmacologico Senono,
J Dis Child 1935;49:923
a rabbit thymosin antiserum against Thymostimu- 6. Minkowttz 5, Wenk R, Friedman E, et al: Acute glomeru-
lin was Thymostimulin was found to lonephritis associated with varicella infection. Am J Med
1968;44:489
be different from Goldsteins thymosin; it was par-
7. Krebs RA, Burvant MU: Nephrotic syndrome in association
tially identified with Goldsteins thymosin factors with vanicella. JAMA 1972;222:325
3 and 5#{149}19Because of its antiviral activity, we used 8. Kerman R, Smith, R, Ezdinli E: Unification and technical
aspects of total T, active T and B lymphocyte rosette assay.
Thymostimulin during the critical period of van-
Immunol Commun 1976;5:685
cella infection. 9. McCoy JL, Maluish AE, Halliday WJ, et al: Indirect agarose
We have measured the OKT4 and OKT8 cell microdroplet leukocyte migration inhibition method, Rose
NR, Friedman X (eds): Manual of Clinical Immunology.
changes in 15 children infected with vanicella. Re-
Washington, DC, American Society for Microbiology, 1980,
sults were variable. In some cases, OKT8 cells were p 252
increased and in others the cells were decreased. 10. Digeon M, Layer M, Riza J, et al: Detection of circulating
immune complexes in human sara by simplified assays with
There were similar results with OKT4 cells. In our
polyethylene glycol. J Immunol Meth 1977;16:165
previous studies of patients who had nephrotic syn- 11. Henoch E: KIm Wochenschr 1884;21:17
drome with frequent relapse and in patients with 12. Rotter R, Collins JD: Fatal disseminated varicella in adults.
Wi.s Med J 1961;60:325
mesangial proliferative glomerulonephritis, high
13. Singhal PC, Chugh KS, Muthusethupathi MA: Rapidly pro-
levels of OKT8 cells were always found during the gressive glomerulonephritis associated with vanicella infec-
nephrotic phase. This suggested that the change in tion. J Pedia.tr 1977;91:680
14. Hosakai M, et al: A case of acute glomerulonephritis devel-
T-cell subsets played an important role in the ne-
oped during the incubation period ofvaricella. Jpn J Pediatr
phrotic syndrome. 1983;36:27
15. Hsu HC, Chan WY, Lin GJ, et al: IgA nephropathy: A
clinico-pathologic study. J Formosan MedAssoc 1982;81:347
16. Lin CY: Lymphocyte subpopulations and lymphoprolifera-
ACKNOWLEDGMENTS tion studies in steroid responsive nephrotic syndrome, ab-
The authors thank Professor Michiaki Takahashi, De- stracted. Sixth International Symposium of Pediatric Ne-
partment of Virology, Osaka University, Osaka, Japan phrology, Hannover, West Germany, Aug 29 to Sept 2, 1983,
146
for the high-titer varicella antiserum and specific van- 17. Steiehm ER, Fulginiti VA: Immunologic Disorders in Infants
cella antigen. The specific bovine thymic extract (Thy- and Children. Philadelphia, WB Saunders Co, 1980, p 335
mostimulin) was donated by Istituto Farmacologico Ser- 18. Falchetti R, Bergesi G, Eshkol A, et al: Pharmacological and
ono, Rome. biological properties of a calf thymus extract LTP-D. Drugs
Under Exp Clin Res 1977;3:39
19. Fiorilli M, Ammirati P, Pandolfi F, et al: Immunological
and clinical investigation of a bovine thymic extract: I. In
REFERENCES
vitro effect on T-cell differentiation in normal and patho-
1. Bates RC, Jennings RB, Eurle DP: Acute nephritis unrelated logical conditions. Ann Sckwo 1974;21:494
to group A hemolytic streptococcus infection. Am J Med 20. Lin CY: In vitro suppressor T cell dysfunction in steroid
1957;23:510 responsive nephrotic syndrome. Presented at the Sixth In-
2. Jensen MM: Viruses and kidney disease. Am J Med 1967; ternational Symposium of Pediatric Nephrology, Hannover,
43:897 West Germany, Aug 29 to Sept 2, 1983

ARTICLES 1131
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 Nephrotic Syndrome Associated with Varicella Infection
Ching-Yuang Lin, Hey-Chi Hsu and Han-Yang Hung
Pediatrics 1985;75;1127
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1985 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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 Nephrotic Syndrome Associated with Varicella Infection
Ching-Yuang Lin, Hey-Chi Hsu and Han-Yang Hung
Pediatrics 1985;75;1127

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/75/6/1127

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1985 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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