Introduction -EBV infections are very common with a spectrum of clinical manifestations and severity, ranging from asymptomatic to multiple organ involvement. Renal involvement is commonly acute kidney injury rather than isolated nephrotic range proteinuria. We describe an infant with a complicated disease course including severe hemolytic anemia and nephrotic range kidney involvement.
The Case - a previously healthy nine months old infant was admitted to the ER with prolonged fever. Evaluation for prolonged fever revealed elevation of Anti-EBNA and decline of Anti-VCA IGM titers with sero-conversion of Anti-VCA antibodies. Urinalysis was strongly positive for protein with otherwise normal results. Protein/creatinine ratio revealed a value of 10.5 (Normal range < 0.2 g/g), while serum creatinine, blood pressure and urine microscopy for erythrocytes and casts were all normal. Blood albumin declined to a nadir of 2.67 mg/dl, triglycerides increased to 382 mg/dl, and periorbital edema was noted. C3 and C4, ANA and ASLO levels were normal. Protein excretion spontaneously recovered to normal values. Hemoglobin declined to 5.7 g/dl. Evaluation revealed low reticulocytes, low iron saturation and a positive DAT (direct coombs) test. Packed red cells transfusion was administered. Repeated peripheral blood smears showed immature and atypical monocytes and lymphocytes with no evidence for blasts. Bone marrow aspiration and biopsy were performed, which revealed reactive bone marrow with no signs of neoplasia.
Discussion - The most common renal involvement associated with EBV infection is acute kidney injury. to the best of our knowledge this is the first case presenting with combined coombs positive acute hemolytic anemia and nephrotic syndrome associated with EBV infection.
