Hypersensitivity angiitis with granulomatous glomerulitis in a patient with preexisting IgA nephropathy

Following a 6-year history of asymptomatic proteinuria and microhematuria, a 51-year-old man suffered from acute systemic eruption, liver dysfunction and acute renal failure immediately after developing a cold and taking drugs including piroxicam, aspirin and bristocycline. Renal biopsy revealed progressive IgA nephropathy associated with acute tubulointerstitial nephritis and granulomatous glomerulitis. Although the drug actually responsible for this condition was not defined, it is likely that drug-induced hypersensitivity angiitis with granulomatous glomerulitis was superimposed on preexisting IgA nephropathy in this patient.     

HYPERSENSITIVITY ANGIITIS WITH GRANULOMATOUS GLOMERULITIS IN A PATIENT WITH PREEXISTING IgA NEPHROPATHY

Following a 6-year history of asymptomatic proteinuria and microhematuria, a 51-year-old man suffered from acute systemic eruption, liver dysfunction and acute renal failure immediately after developing a cold and taking drugs including piroxicam, aspirin and bristocycline. Renal biopsy revealed progressive IgA nephropathy associated with acute tubulointerstitial nephritis and granulomatous glomerulitis. Although the drug actually responsible for this condition was not defined, it is likely that drug-induced hypersensitivity angiitis with granulomatous glomerulitis was superimposed on preexisting IgA nephropathy in this patient. ACTA PATHOL JPN 38: 209–216, 1988.     

Thin basement membrane nephropathy as a cause of recurrent haematuria in childhood

A survey of 69 children presenting with recurrent or persistent haematuria and submitted to percutaneous renal biopsy at this hospital over a 17-year period, was performed to establish the incidence of thin basement membrane nephropathy (TBMN). A diagnosis of primary glomerular disease was established in 44 (IgA nephropathy in 16, Alport's syndrome in 13 and other varieties of glomerulonephritis in 15). Of the remaining 25 patients in whom light microscopical and immunochemical examination revealed no abnormalities, material for electron microscopy was available in 11. In eight of these (five of whom had a family history), TBMN was diagnosed on the basis of ultrastructural morphometric evaluation of glomerular basement membrane thickness. Assuming a similar proportion of the remaining 14 patients with renal biopsy specimens normal by light microscopy had TBMN, the probable frequency of this abnormality in the whole series would be 26%, very similar to that of IgA nephropathy. In the eight TBMN patients the mean glomerular basement membrane thickness ranged between 181 and 236 nm, whilst in 'control' biopsies from children with 'minimal change' nephrotic syndrome or IgA nephropathy, the mean thickness ranged between 242 and 333 nm.     

Report of a patient of primary Sj?gren syndrome, IgA nephropathy and chronic idiopathic thrombocytopenic purpura]

We describe the case of a 61-year-old woman diagnosed with primary Sj?gren's syndrome (SS) after an 8-year history of IgA nephropathy and a 3-year history of recurrent purpuric rashes. Her two daughters had previously been diagnosed with other autoimmune diseases. One daughter had Graves' disease and the other had Hashimoto's disease and systemic lupus erythematosus. The diagnosis of SS was made based on dryness of mucous membranes, Shirmer test, and parotid sialography. Thrombocytopenia, high platelet-aggregated IgG (PA-IgG) level, and normal megakaryocytes count in bone marrow suggested that her recurrent purpuric rashes were due to idiopathic thrombocytopenic purpura (ITP). Patients with SS may develop other autoimmune diseases. This case aids understanding of the immune pathogenesis and genetic background of SS.     

Chronic mucocutaneous candidiasis and oesophageal cancer.

Chronic mucocutaneous candidiasis (CMC) is often accompanied by endocrine or inflammatory disorders. The association of CMC with squamous cell carcinoma of the oral cavity or oesophagus have been described in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED). We describe three cases of CMC and oesophageal cancer without the APECED syndrome. The first case refers to a 41-year-old man with Candida paronychia and oral infection and selective IgA deficiency since childhood, who later developed an oesophageal cancer. The second case is a 30-year-old man who presented CMC features at the age of 2 together with selective IgA deficiency. Later on he was diagnosed with an oesophageal squamous cell carcinoma. His mother, the third case reported, had oral thrush since childhood and at the age of 29 she presented with an oesophageal squamous cell carcinoma. The three patients reported died due to oesophageal cancer. This is the first case report describing the development of oesophageal cancer in patients with CMC without the APECED syndrome. Patients with CMC need close follow-up with good oral hygiene and aggressive treatment of oral and oesophageal candidiasis. Routine endoscopic screening for patients with CMC that develop symptoms of oesophageal candidiasis and for patients with CMC with a family history of oesophageal cancer is suggested. Avoidance of additional risk factors for oral and oesophageal cancer like cigarette smoking and excessive alcohol consumption are also warranted.     

Phenotypic variability in two patients with tumor necrosis factor receptor associated periodic fever syndrome emphasizes a rare manifestation: Immunoglobulin A nephropathy

Tumor necrosis factor receptor associated periodic fever syndrome (TRAPS) is caused by heterozygote mutations in TNFRSF1A, characterized by recurrent inflammatory attacks.In this report, we described two patients with different heterozygote mutations in TNFRSF1A. Patient 1, a 15-year-old male, had suffered from recurrent fever attacks accompanied by abdominal pain, eye manifestations, and myalgia with increased acute phase reactants since the age of 6-month. He had been unsuccessfully treated with colchicine for having familial Mediterranean fever without an identifiable MEFV mutation since the age of 4-year. At the age of 15 years, he was diagnosed with immunoglobulin (Ig) A nephropathy due to massive proteinuria and renal biopsy findings. Next generation sequencing revealed NM_001065.3: c.236C>T; p. (Thr79Met); T50M heterozygote mutation in TNFRFS1A. He was treated with methylprednisolone and cyclosporine for IgA nephropathy, thereafter with canakinumab for TRAPS. Patient 2, a 17-year-old female, had recurrent arthritis attacks accompanied by increased acute phase reactants for the last two months. She had neither fever attacks nor rashes or myalgia. Her physical examination was normal between attacks. Magnetic resonance imaging of both knees and ankles showed no signs of chronic arthritis. MEFV analyzes showed no mutation. Next generation sequencing revealed NM_001065.3: c.362G>A; p.(Arg121Gln); R92Q heterozygote mutation in TNFRFS1A. Arthritis attacks were treated successfully with ibuprofen thereafter.In conclusion, we wish to emphasize the diversity of the clinical manifestations between these two patients with distinct sequence variants in TNFRSF1A. Moreover, we presented a rare manifestation of TRAPS, IgA nephropathy.     

Immunoglobulin A nephropathy complicating pulmonary tuberculosis.

A 31-year-old man who presented with smear- and culture-negative pulmonary tuberculosis had associated macroscopic hematuria, elevation of serum creatinine and immunoglobulin A (IgA) levels, overt proteinuria, and peripheral edema. Renal biopsy revealed focal mesangial proliferation with IgA deposits, and a diagnosis of IgA nephropathy was made. The patient received treatment with isoniazide and rifampin. After 4 months, pulmonary lesions were almost completely healed, and a significant improvement of creatinine clearance with normalization of serum creatinine and IgA levels and disappearance of proteinuria were observed. Treatment with isoniazide and rifampin was discontinued after 6 months, without reappearance of either pulmonary or renal symptoms. Two years after the diagnosis of IgA nephropathy, the patient is in good general condition. Serum creatinine and IgA levels are normal, proteinuria is absent, and there is neither macrohematuria nor microhematuria. These findings suggest that IgA nephropathy may be a consequence of tuberculosis, possibly due to an abnormal IgA-mediated immune response against Mycobacterium tuberculosis with formation of nephrotoxic immune complexes.     

Minimal change disease complicated by contrast-induced nephropathy

We present a clinical case with histopathological findings of an adult presentation of nephrotic syndrome complicated by acute kidney injury (AKI) following a CT contrast study. A 45-year old female with no significant past medical history was admitted following a 1 week history of peripheral oedema. She developed AKI following CT abdomen and pelvis with contrast, before being transferred to the renal team and being diagnosed with nephrotic syndrome. Histopathological assessment of a renal biopsy displayed evidence of both acute tubular injury and minimal change disease (MCD). To the author's knowledge, this is the first documented case of MCD complicated by contrast-induced nephropathy, with evidence of both pathologies on electron microscopy. Clinically, such cases emphasise the need for awareness of susceptibility to AKI in patients with MCD.     

A case of sarcoidosis revealed in the course of IgA nephropathy

A 36 year old man, who had been proteinuric for 14 years due to immunoglobulin A (IgA) nephropathy, was admitted because of an acute exacerbation in renal dysfunction with hypercalcemia. He had presented with aortic regurgitation and increased pulmonary marking by chest X-ray, but laboratory examinations had failed to make an exact diagnosis, On admission, noncaseating epithelioid granulomas were disclosed by muscle and skin biopsies. Ophthalmological evaluation revealed old uveitis and retinal changes conslstent with sarcoidosis. In this case, IgA nephropathy was thought to be the initial manifestation of sarcoidosis that developed latently. Sarcoidosis should be considered in a differential diagnosis of IgA nephropathy.     

The role of reduced calorie intake test in diagnosing Gilbert syndrome--a case report.

This article describes a 29-year-old man with a 21-year history of undiagnosed jaundice. The major abnormality in this patient was unconjugated hyperbilirubinemia. All other liver function tests were normal. The apparent cause of his condition was elucidated, and the hyperbilirubinemia disappeared after he was treated with phenobarbitone. A review of the literature indicates that this is the first documented case of this syndrome in the English-speaking Caribbean.     

Two cases of epithelioid angiosarcoma involving the thyroid and a brief review of non-Alpine epithelioid angiosarcoma of the thyroid

Epithelioid angiosarcoma involving the thyroid is a rare entity, more often described in the Alpine region. Two cases of epithelioid angiosarcoma that affected the thyroid in patients from a non-Alpine location were diagnosed during a 10-year period in our department. The first case occurred in an 89-year-old Chinese man with a history of longstanding goiter, whereas the second case involved a 74-year-old Chinese man with a history of angiosarcoma of the scalp. On histologic examination, both thyroid tumors were composed of plump epithelioid cells with vesicular chromatin and prominent nucleoli, forming vascular structures and solid sheets. Positive staining for CD31 and factor VIII-related antigen confirmed endothelial differentiation in both cases. Both patients died within 5 months following the diagnosis of thyroid disease. The relationship of the scalp angiosarcoma and thyroid disease of the second patient is unclear. A brief review of non-Alpine primary thyroid epithelioid angiosarcoma is presented.     

Membranous nephropathy. Its association with multicentric angiofollicular lymph node hyperplasia.

Multicentric angiofollicular lymph node hyperplasia of the plasma cell type with systemic manifestations developed in a 51-year-old man. One year later, the nephrotic syndrome due to typical immune complex mediated membranous nephropathy developed. Elevated titers to Epstein-Barr viral antigens suggesting reactivation of a latent infection were present. The patient has required conservative medical management only. The association of membranous nephropathy with angiofollicular lymph node hyperplasia lends further evidence to the postulate that the disorder is a manifestation of chronic immune stimulation by a foreign antigen.     

粘附分子选择素在IgA肾病中变化的临床意义

目的：为探讨ＩｇＡ肾病患者血和肾组织中Ｐ选择素必变与疾病的关系。方法：采用酶联免疫吸附法、免疫组化及原位杂交技术检测了４５例ＩｇＡ肾病患者血浆和肾组织中Ｐ选择素含量及表达水平。结果：ＩｇＡ肾病患者血浆Ｐ选择素含量明显高于正常人,其中肾病综合征组和肾功能减退组含量又较肉眼血尿组、尿检异常组和肾炎综合征组显著增高造反素在患者肾组织中广泛表达,其中在Ⅳ级和Ⅴ级ＩｇＡ肾病肾小球中表达水平明显高于Ⅱ级和Ⅲ级     

Immunopathological similarities between IgA nephropathy and Henoch-Schoenlein purpura (HSP) nephritis

A study on the immunopathological similarities between IgA nephropathy and Henoch-Schoenlein purpura (HSP) nephritis is described. Various examinations were performed as follows. (1) Pathological studies: light microscopic findings and immunofluorescent staining; (2) Measurement of the levels of IgA in pharyngeal washings and sera, and those of IgA quantitated by radial immunodiffusion; (3) Elution studies: renal biopsy specimens obtained from patients with IgA nephropathy and HSP nephritis were treated with citrate buffer (pH 3.2) and the "eluate" was neutralized by sodium hydroxide. The "eluate" was then applied to the acid-treated sections obtained from the same and other patients with IgA nephropathy as well as sections from patients with HSP nephritis and other glomerular diseases. The sections were stained with FITC-conjugated heavy chain specific antihuman IgA antisera and then examined with a fluorescent microscope. There were no differences in pathological findings of IgA nephropathy and HSP nephritis in the light microscopic and immunofluorescent examinations. The levels of IgA in pharyngeal washings and sera were significantly increased in patients with both diseases. IgA antibodies deposited in kidneys from patients with HSP nephritis crossreacted with kidneys from some patients with IgA nephropathy, and vice versa. However, antibodies from patients with IgA nephropathy and HSP nephritis did not react with normal glomeruli or other nephritic glomeruli. It is concluded that there are some immunopathological similarities between IgA nephropathy and HSP nephritis.     

IMMUNOPATHOLOGICAL SIMILARITIES BETWEEN IgA NEPHROPATHY and HENOCH-SCHOENLEIN PURPURA (HSP) NEPHRITIS

A study on the immunopathological similarities between IgA nephropathy and Henoch-Schoenlein purpura (HSP) nephritis is described. Various examinations were performed as follows. (1) Pathological studies: light microscopic findings and immunofluorescent staining; (2) Measurement of the levels of IgA in pharyngeal washings and sera, and those of IgA quantitated by radial immunodiffusion; (3) Elution studies: renal biopsy specimens obtained from patients with IgA nephropathy and HSP nephritis were treated with citrate buffer (pH 3.2) and the "eluate" was neutralized by sodium hydroxide. The "eluate" was then applied to the acid-treated sections obtained from the same and other patients with IgA nephropathy as well as sections from patients with HSP nephritis and other glomerular diseases. The sections were stained with FITC- conjugated heavy chain specific antihuman IgA antisera and then examined with a fluorescent microscope. There were no differences in pathological findings of IgA nephropathy and HSP nephritis in the light microscopic and immunofluorescent examinations. The levels of IgA in pharyngeal washings and sera were significantly increased in patients with both diseases. IgA antibodies deposited in kidneys from patients with HSP nephritis crossreacted with kidneys from some patients with IgA nephropathy, and vice versa. However, antibodies from patients with IgA nephropathy and HSP nephritis did not react with normal glomeruli or other nephritic glomeruli. It is concluded that there are some immunopathological similarities between IgA nephropathy and HSP nephritis.     

An overlapping syndrome of IgA nephropathy and lipoid nephrosis

The authors studied eight cases of IgA nephropathy presenting with nephrotic syndrome. Renal biopsy revealed only mild mesangial proliferation or minor glomerular changes on light microscopic examination but typical features of IgA nephropathy on immunofluorescent and electron microscopic examination. A satisfactory response characterized by correction of hypoalbuminemia, clearance of proteinuria, and an increase of endogenous creatinine clearance occurred with corticosteroid therapy. These cases represent a variant of IgA nephropathy associated with a nephrotic syndrome that resembles lipoid nephrosis in its responsiveness to steroid.     

Etiology of IgA nephropathy syndrome

Since Berger's original paper on mesangial IgA-IgG deposition with hematuria, there have been a number of clinical and pathological studies regarding IgA immune complexes, the mechanisms of glomerular IgA deposition leading to glomerular injury and animal models of IgA nephropathy. During the last quarter of this century, glomerular changes such as IgA nephropathy have also been observed in cases associated with other diseases, such as systemic lupus erythematosus, Schoenlein-Henoch purpura, liver cirrhosis and chronic inflammatory diseases of the lung. This evidence supports the idea of an IgA nephropathy syndrome. On the other hand, IgA is thought to be an important humoral factor at the mucosal immune system and appears to have an antibody function against various etiologic candidates of extrinsic or intrinsic substances at the mucosal and systemic immune system. Glomerular IgA deposition in IgA nephropathy syndrome is thought to result from elevated levels of circulating immune complexes or aggregated IgA due to an overproduction of polymeric IgA as antibodies in the serum and due to the clearance impairment of IgA immune complexes in the hepatic and splenic phagocytic system. The glomerular IgA subclass is not one-sided, but should be evaluated in comparison with the age of patients at renal biopsy; this indicates the approximate age of onset. Cirrhotic IgA glomerulonephritis is not related to Hepatitis B or C virus infection, but to the pathophysiologic condition of liver cirrhosis. Various etiologic candidates such as viral, microbial, dietary antigens or auto-antigens have been listed and experimental models of IgA nephropathy syndrome have provided some clues in understanding the etiology of primary IgA nephropathy. However much still remains to be clarified and some specific epitopes common among these etiologic candidates will have to be identified.     

Guillain-Barré like syndrome associated with acute renal failure and thrombocytopenia following acute viral hepatitis A.

We reported a 43-year-old woman who showed a Guillain-Barré like syndrome associated with acute renal failure (ARF) and thrombocytopenia following acute viral hepatitis A(HA). The clinical feature was acute progressive and of ascending symmetric paraparesis which developed 5 days after gastrointestinal infection. Neurologic examination showed flaccid paraparesis, areflexia in all extremities and limitation on the straight leg raising test. Laboratory examinations showed the evidences of ARF, thrombocytopenia and HA. EMG findings suggested a polyradiculopathy. Renal biopsy showed the findings of acute interstitial nephritis, acute tubular necrosis and IgA deposition nephropathy. She was treated by plasmapheresis and platelet transfusion, then showed a rapid improvement, and has been well without further complication after discharge.     

Permanent bilateral cortical blindness due to reversible posterior leukoencephalopathy syndrome

Reversible posterior leukoencephalopathy syndrome (RPLS) is induced by acute cerebral edema. Its symptoms include seizures, headache, altered mental status, and visual disturbances. The clinical and radiological findings are usually transient. This report describes a case of RPLS resulting in bilateral total blindness. A 40-year-old man presented with lethargy and bilateral visual loss. He had a 20-year history of hypertension, but had never been treated. On presentation, the left eye was able to perceive light, but the right eye was not. Radiological examination showed diffuse edema in the brain, and ocular fundus examination revealed severe bilateral hypertensive retinopathy. Antihypertensive therapy improved the patient's general condition, including blood pressure. Radiological findings 5 months later showed resolution of most of the abnormal signal areas. However, total blindness had developed in both eyes by day 15, and two courses of pulsed corticosteroid therapy failed to restore the visual loss.     

Familial IgA nephropathy. Evidence of an inherited mechanism of disease

The evaluation of familial glomerulonephritis in patients with IgA nephropathy who were from central and eastern Kentucky resulted in the discovery of potentially related pedigrees containing 14 patients. An additional 17 members of the pedigrees had clinical glomerulonephritis, and 6 had "chronic nephritis" noted on their death certificates. Six patients with IgA nephropathy had a common ancestor. In addition, both parents of six patients with the disease came from families with other cases of IgA nephropathy. No single HLA haplotype or antigen was found in all the patients with IgA nephropathy. Our data on these pedigrees strongly support an inherited mechanism in the pathogenesis of IgA nephropathy in some patients.