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      Uncommon cause of fever in a child with steroid-dependent nephrotic syndrome

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          Abstract

          Background: Children with nephrotic syndrome are vulnerable to developing infections due to a state of relative immunodeficiency, malnourishment, and use of immunosuppression. Case characteristics: We herein report the case of a 3-year-old child with steroid-dependent nephrotic syndrome who presented to us with fever of unknown origin. Observation: The child was found to have an atypical mixed infection with mycoplasma and cytomegalovirus. Outcome: The infection completely resolved with appropriate treatment and lowering of immunosuppression. Message: Persistently febrile pediatric patients, especially in the setting of recent immunosuppression and absence of otherwise-identified infectious pathogens, should be screened for atypical mixed infections.

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          Most cited references24

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          Fever of Unknown Origin: A Clinical Approach

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            Fever of unknown origin.

            More than 50 years after the first definition of fever of unknown origin (FUO), it still remains a diagnostic challenge. Evaluation starts with the identification of potential diagnostic clues (PDCs), which should guide further investigations. In the absence of PDCs a standardised diagnostic protocol should be followed with PET-CT as the imaging technique of first choice. Even with a standardised protocol, in a large proportion of patients from western countries the cause for FUO cannot be identified. The treatment of FUO is guided by the final diagnosis, but when no cause is found, antipyretic drugs can be prescribed. Corticosteroids should be avoided in the absence of a diagnosis, especially at an early stage. The prognosis of FUO is determined by the underlying cause. The majority of patients with unexplained FUO will eventually show spontaneous remission of fever. We describe the definition, diagnostic workup, causes and treatment of FUO.
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              Donor serostatus has an impact on cytomegalovirus-specific immunity, cytomegaloviral disease incidence, and survival in seropositive hematopoietic cell transplant recipients.

              More cytomegalovirus (CMV)-specific T cells are transferred with grafts from CMV seropositive than seronegative donors. We hypothesized that seropositive recipients of grafts from seropositive donors (D+R+) have higher counts of CMV-specific T cells than seropositive recipients of grafts from seronegative donors (D-R+), and that this is clinically relevant in the setting of in vivo T cell depletion using rabbit-antihuman thymocyte globulin (ATG). We reviewed charts of 298 ATG-conditioned, seropositive recipients for CMV reactivation (pp65 antigenemia or CMV DNAemia above institutional threshold for preemptive therapy), recurrent CMV reactivation, CMV disease, and death. In 77 of these patients, we enumerated CMV-specific T cells. Median follow-up was 564 days. CMV-specific CD4+ and, to a lesser degree, CD8+ T cell counts were higher in D+R+ than D-R+ patients. D+R+ patients had lower cumulative incidence of CMV reactivation (21% versus 48%, P < .001), recurrent reactivation (4% versus 15%, P = .003), CMV disease (3% versus 13%, P = .005) and mortality (42% versus 56%, P = .006). We conclude that in the setting of in vivo T cell depletion using ATG, seropositive donors should be used for seropositive recipients. For scenarios where only seronegative donors are available, strategies to improve CMV-specific immunity (e.g., donor vaccination) should be explored. Copyright © 2011 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Clin Nephrol Case Stud
                Dustri
                Clinical Nephrology. Case Studies
                Dustri-Verlag Dr. Karl Feistle
                2196-5293
                2020
                7 July 2020
                : 8
                : 49-52
                Affiliations
                [1 ]Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India, and
                [2 ]Akron General Medical Center, and
                [3 ]Akron Children’s Hospital, Akron, OH, USA
                Author notes
                Correspondence to: Dr. Sidharth Kumar Sethi, Consultant Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, 122001 Gurgaon, Haryana, India sidsdoc@ 123456gmail.com
                Article
                10.5414/CNCS110062
                7344764
                a28c188e-75f8-41c7-af7b-2bffd6c14d97
                © Dustri-Verlag Dr. K. Feistle

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

                History
                : 27 November 2019
                : 8 April 2020
                Categories
                Case Report
                Nephrology

                cmv disease,fever of unknown origin,mixed opportunistic infection,mycoplasma pneumoniae,steroid-dependent nephrotic syndrome

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