SLIDE 1

Good morning. We would like to present our case study entitled “ A Case of the Disease after SARS-CoV-
2 Vaccination under the Age of 18”.

SLIDE 2

Our presentation will tackle the following points. Case presentation, Diagnosis, and A Quick Discussion
of the disease which will be revealed later on.

SLIDE 3

Our case involves a 16-year old white man

SLIDE 4

Upon consultation, he presented with swelling in his legs as edema. Subsequently, he reported
abdominal discomfort with nauseating episodes. Further, progressive swelling on his ankles and 10
kilogram weight gain was noticed.

SLIDE 5

So let’s look at the medical history that he had declared. He denied any infection and malignancy
histories. Additionally, he was not on any supplements and medications. The most significant
declaration was that he received the second dose of Pfizer vaccination. Seven days after the
immunization, the primary complaint of leg swelling was noticed.

SLIDE 6

Physical examination was performed. The reported blood pressure was 115/74 mmHg with a pulse rate
of 99 beats per minute.

SLIDE 7

His physician also observed significant bilateral pitting edema up to the thighs. A decreased breathing
sound on both his lungs with dullness to percussion. Basically dull percussions occur when solid or liquid
substances are over the air filled-lungs. This may be caused my either pneumonia, effusions, or tumors.

SLIDE 8

For his laboratory work up, these are the tests and corresponding values. His serum creatinine was 0.85
mg/dL, which means a normal renal function. Serum albumin of 1.5 g/dL which means the patient
suffers from hypoalbuminemia. His urinalysis shows 4+ protein; a massive proteinuria and moderate
blood with protein to creatinine ratio 5.6 g/g.

SLIDE 9

As additional tests, tests for antinuclear cytoplasmic antibody, C3, C4 , hepatitis B and C panels were
negative.

His renal ultrasound revealed11 cm bilateral kidneys with slight increased echogenicity, a non-specific
marker of renal disease.
 SLIDE 10

The most significant test performed was done after the patient was collected a sample from a renal
biopsy. Light microscopy of the biopsy which contains 56 glomeruli shows a normal glomeruli. Now take
note, standard microscopy showed no abnormal changes. However, electron microscopy was performed
showed diffuse “podocyte foot processes effacement”. As we have learned, podocytes have these
interdigitating foot processes which helps as a slit. However, these had flattened or erased. Now
remember this was only seen using a highly magnifying electron microscope. To add,
immunofluorescence studies were all negative

SLIDE 11

After being diagnosed by the disease, the patient was started on 60 mg of oral prednisone, a steroid,
together Olmesartan and furosemide. And take note, after a week of treatment, his edema resolved and
serum albumin and proteinuria had started to improve.

SLIDE 12

For the first question, when looking at this group of signs and symptoms, what syndrome does it reflect?

Nephrotic syndrome. Yes you are right it is.

SLIDE 13

Now for the second question, what is the disease that have caused the nephrotic syndrome?
The answer would be minimal change disease

SLIDE 14
Now before we discuss the disease. I wanted to clarify the difference between a syndrome and a
disease. This is from the university of Utah. Basically, syndrome is a group of signs and
symptoms which can point a disease but not definitively. A disease on the other hand has
distinguishing signs and symptoms which has a defining cause and unique treatment. A
syndrome like nephrotic syndrome may point to different diseases. We have learned from our
AUBF class that it can be caused by membranous glomerulonephritis (MGN), focal segmental
glomerulosclerosis (FSGS), Alport syndrome, and Minimal Change Disease to name from
glomerular disorders. Hence, to cancel out other diseases, clinicians use history, laboratory tests
to define what specific disease had caused that general syndrome.
 SLIDE 15
As discussed from our lectures, Minimal change disease is one of the most common causes of
nephrotic syndrome, primarily, in children. Fundamentally, albumin which is not normally
filtered becomes filtered due to the disruption of podocytes. This low serum albumin can’t
maintain the oncotic pressure inside the bloodstream, so water goes out extra vascularly which
is evidenced by the edema observed from our patient. This is in addition to the proteinuria,
hematuria but a normal renal function (normal creatinine) from the case that is also discussed
from our lecture. The only sign that was not discussed from our case was the lipiduria which was
written in our module.
The most important feature of MCD is that it is not associated with much cellular change in
glomeruli. This is why the investigators needed the use of an electron microscope to see the
diffuse foot process effacement of podocytes which was not evident in standard microscope,
hence the name minimal change.
Our lecture also discussed that MCD patients responds well with corticosteroids within a month,
this correlates with our patient when treated with prednisone (a steroid) that his edema had
resolved.
Hence, it is correlating the more favorable prognosis than the nephrotic syndrome.
Lastly, MCD is usually followed by many causes including immunization which was also discussed
from our lectures evidenced by the history of Pfizer vaccination from our patient.

SLIDE 16
Additional information that may have not been supplemented from our lecture is the specific
use of electron microscopy as a confirmatory test for MCD. Although distant from this case, we
know that Pfizer is the first COVID-19 vaccine that was approved by the FDA to be administered
to 12-17 year-old patients, hence that common reports of MCD to teenager patients injected
with Pfizer. Lastly, it was postulated by the investigators that T-cell activation may have been
the main mechanism for MCD pathophysiology.

SLIDE 17
Now for our question time.
1. What was the COVID-19 vaccine administered to the patient in this case? After what dose did
the patient developed sudden edema?
A. Pfizer; first primary dose
B. Pfizer; second primary dose
C. Pfizer; booster dose
D. None of the above

2. What was the confirmatory test used to identify the disease in this case study?
A. Light microscopy
B. Renal ultrasound
C. Electron microscopy
D. Immunofluorescence studies

Thank you and God bless!