IgA nephropathy associated with seronegative spondylarthropathies

Membranous glomerulonephritis in a patient with ankylosing spondylitis: a rare association

Ankylosing spondylitis is a chronic inflammatory disease of the vertebral joints and soft tissues. Renal involvement, apart from amyloidosis, is rare in this disorder. Of the various glomerulonephritides reported in association with ankylosing spondylitis, IgA nephropathy is the most common. Membranous glomerulonephritis occurs very rarely in patients with ankylosing spondylitis, and only four such cases have been reported in the available English literature. Due to the rarity of this association, membranous glomerulonephritis may not initially be considered in patients with ankylosing spondylitis and proteinuria. We report the case of a 29-year-old man with ankylosing spondylitis who presented with pedal edema and was detected to have nephrotic syndrome. A percutaneous renal biopsy showed features of membranous glomerulonephritis with capillary wall granular deposits of IgG and C3 on immunofluorescence and subepithelial immune complex deposits on electron microscopy. No other secondary cause of membranous glomerulopathy was found on extensive investigations. Membranous glomerulonephritis is extremely rare in association with ankylosing spondylitis, the present case being the fifth such report. The exact relationship of these two entities (etiological or coincidental) still needs to be elucidated. The occurrence of this rare association needs to be recognized and differentiated from other more common causes of renal involvement in ankylosing spondylitis.

Reiter's syndrome: the classic triad and more

Reiter's syndrome, also known as reactive arthritis, is the classic triad of conjunctivitis, urethritis, and arthritis occurring after an infection, particularly those in the urogenital or gastrointestinal tract. Dermatologic manifestations are common, including keratoderma blennorrhagicum, circinate balanitis, ulcerative vulvitis, nail changes, and oral lesions. Epidemiologically, the disease is more common in men, although cases have also been reported in children and women. The pathophysiology has yet to be elucidated, although infectious and immune factors are likely involved. Clinical presentation, severity, and prognosis vary widely. Treatment is difficult, especially in HIV-positive patients. Prognosis is variable; 15% to 20% of patients may develop severe chronic sequelae.

Coexistence of IgA nephropathy and undifferentiated spondyloarthropathy in a female patient

We report a female patient with IgA nephropathy associated with undifferentiated spondyloarthropathy. The patient manifested proteinuria and microhematuria and was diagnosed as having IgA nephropathy based on the histopathologic findings of the renal biopsy. Two years later, the bone X-ray demonstrated syndesmophytes and multiple calcifications in the ligament and tendon insertions, suggestive of long-term enthesitis, but the patient had occasionally noticed mild lumbago up to the time she visited our hospital, with spontaneous pain in the bilateral shoulders and lower back. IgA nephropathy can be concomitant with a mild form of seronegative spondyloarthropathy in women. Possible association of this disorder should be carefully checked in patients with IgA nephropathy irrespective of clinical symptoms suggesting the arthropathy, particularly in women.

[IgA nephropathy]

IgA nephropathy is glomerular disease first described in 1968 by Berger, named after him Morbus Berger. The disease is characterized by the presence of IgA dominant or codominant immunoglobulin deposits in glomerular mesangium which can be demonstrated by immunofluorescence. Clinical manifestations of IgA nephropathy in the majority of cases is hematuria which can be macro or microscopic, isolated or combined with proteinuria which can be of nephrotic range. In some cases nephrotic syndrome can be the first clinical presentation. In 10% renal insufficiency can be present at the onset of the disease. By light microscopy IgA can manifest any of the histologic phenotypes of immune complex mediated proliferative glomerulonephritis. According to light microscopy findings a classification system have been used to categorize the histologic patterns of IgA nephropathy. Glomerular changes in IgA nephropathy are proliferative and can be focal or diffuse accompanied by crescentic formation in many cases. Immune deposits seen by electron microscopy appear as electron dense deposits most numerous in mesangium.

Increase in immunoglobulin G3-secreting cells in intractable Graves' disease

Isotype switching of immunoglobulin (Ig)-secreting cells is regulated by a set of cytokines. In the present study, we studied the relation between the number of peripheral blood mononuclear cells spontaneously secreting IgG, IgM, IgA, and their subclasses and the disease severities in autoimmune thyroid diseases. Ig-secreting cells were measured by enzyme-linked immunospot (ELISPOT) assay in 99 euthyroid patients with Graves' disease (GD) or Hashimoto's disease (HD) and 13 normal subjects. The number of IgG3-secreting cells was significantly higher in patients with intractable GD who had been undergoing treatment with antithyroid drugs for more than 5 years but who did not go into remission than in patients with GD in remission. This number correlated significantly with the serum level of thyrotropin receptor antibody (TRAb) in all patients with GD. These data suggest that the number of IgG3-secreting cells whose isotype switching is stimulated by interleukin (IL)-10 and IL-4 may be related to the disease severity of GD and to the level of TRAb after long-term treatment with antithyroid drugs.

Renal abnormalities in a population of patients with psoriatic arthritis

OBJECTIVE

To investigate the prevalence of and to identify predictive factors for renal abnormalities in patients with psoriatic arthritis (PsA).

METHODS

73 patients with PsA were consecutively examined by laboratory analyses and clinically for joint manifestations. Renal function was estimated by creatinine clearance and urinary albumin.

RESULTS

17 (23.3%) of the patients had renal abnormalities as defined by creatinine clearance below the lower cut off of normal distribution (mean - 2 SD) and/or urinary excretion of albumin more than 25 mg/24 h. These patients were significantly older at the time of the study, older at joint disease onset, had longer skin disease duration, increased serum levels of beta2-microglobulin, and higher incidence of increased ESR and/or CRP levels. Increased ESR/CRP levels had significantly predictive value in multivariate analysis.

CONCLUSIONS

In this study subclinical renal abnormalities was a prevalent finding. Predictive factor was inflammatory activity measured by laboratory variables. There were no predisposing effects of NSAID or DMARD therapy.

Renal failure and cholestatic jaundice as unusual complications of childhood pustular psoriasis

Generalized pustular psoriasis (GPP) is uncommon in children, and serious renal and liver complications arising from GPP are rarely reported. We describe a Chinese boy who had suffered from recurrent exacerbations of GPP from the age of 1 year. He developed IgA nephropathy at the age of 9 years. He also had recurrent episodes of oliguric renal failure, hepatomegaly and cholestasis associated with severe exacerbations of GPP. These complications progressed despite early antibiotics and supportive therapy, but responded promptly to intravenous methylprednisolone therapy. Ultimately, acitretin was given and he has successfully been in remission for a year.

Renal diseases in ankylosing spondylitis: review of the literature illustrated by case reports

Ankylosing spondylitis (AS) can be accompanied by extraarticular manifestations in the cardiovascular, pulmonary, neurologic and renal organs. Secondary renal amyloidosis is the most common cause of renal involvement in AS (62%) followed by IgA nephropathy (30%), mesangioproliferative glomerulonephritis (5%) as well as rarely membranous nephropathy (1%), focal segmental glomerulosclerosis (1%) and focal proliferative glomeruleonephritis (1%). Treatment associated nephrotoxicity may result from non-steroidal anti-inflammatory drugs or disease modifying agents. The purpose of this paper was to alert for the possibility of renal damage in AS and to analyse the frequencies of different etiologies of renal involvement. Two typical case reports of renal involvement in AS are presented to illustrate the clinical course of such patients. Renal side effects and possible pre-existing renal diseases should be taken into account while choosing the appropriate medication for patients with AS.

Systemic vasculitis associated with seronegative spondylarthropathy (Reiter's syndrome)

A first case of Reiter's syndrome developing a severe systemic necrotising vasculitis is reported. After a disease course with major complications, aggressive consistent immuno-suppressive treatment was successful.

Renal abnormalities in ankylosing spondylitis

Renal abnormalities have been reported in Ankylosing Spondylitis (AS) patients. Possible mechanisms include the effects of nonsteroidal anti-inflammatory drugs (NSAIDs), an increased incidence of glomerulonephritis, particularly the ones associated with deposition of IgA-containing immune complexes and the renal deposition of amyloid. These observations prompted us to evaluate in detail the frequency and severity of renal dysfunction in 40 AS patients, consecutively selected attending the rheumatology disease unit outpatient clinic at Escola Paulista de Medicina, using sensitive tests of glomerular and tubular function. Fourteen of the 40 patients presented one or more signs of renal involvement: microscopic hematuria (9 patients), microalbuminuria (4 patients), decreased renal function assessed by serum creatinine (2 patients), and creatinine clearance (4 patients). None of the patients presented increased urinary excretion of retinol binding protein (RBP). The finding of renal abnormalities in 35% of our patients suggests that in this illness evidence of renal involvement should be actively investigated.

Serum secretory immunoglobulins in ankylosing spondylitis

Humoral mucosal immunity may be implicated in pathophysiology of ankylosing spondylitis (AS). The aim of the study was to evaluate serum levels of IgA, IgM and secretory IgA (sIgA), secretory IgM (sIgM) as well as free secretory component (FSC) in patients with AS compared to controls and rheumatoid arthritis (RA) patients. Levels of sIgA, sIgM and FSC were measured with a specific ELISA in 37 AS patients, 45 controls and 27 RA. The results were as follows: Serum levels of IgA were higher in AS vs controls and in RA vs controls (p = 0.01). Levels of sIgA were higher in AS vs controls (p = 0.01), but higher in RA vs AS (p = 10(-4)). There was no difference of sIgM in AS vs controls, FSC levels were higher in AS vs controls, and higher in AS patients with elevated CRP. In view of elevated FSC, this increase of sIgA in AS may have been due to excessive production of mucosal IgA after bacterial stimulation according to the current hypothesis of the disease.

[Spondylarthropathies and the IgA system]

The spondyloarthropathies (SA) implicate bacterial infections of mucosal origin. IgA synthesis capacity in vitro is normal in AS. IgA increase is secondary to a specific immune response to the bacterial antigens implicated in the disease's pathogenesis. IgA participate to immune complex formation, which may lead to some extraarticular features of the disease (e.g. renal, cutaneous or vascular). There is also an increase of secretory IgA reflecting the activation of the two compartments of this humoral immune response, part of a coherent pathophysiological scheme of the disease. In a practical point of view, IgA serum levels may be considered as a biological parameter of SA activity.

[Nailfold capillaroscopy and ankylosing spondylarthritis: incidence of anomalies, but absence of diagnostic and prognostic value]

Vascular involvement is seldom reported in ankylosing spondylitis (AS). In this study, microcirculation was evaluated by nailfold capillaroscopy in 32 defined AS patients compared to a control group (C) of 14 sciatica. Capillary findings were divided into five groups: normal, minor dystrophies, edema, microangiopathy, stagnation. Capillaroscopic abnormalities were more frequent in SA as compared to C, for edema (40% vs 7%) and microangiopathy (15% vs 0%). P = 0.01. There were neither clinical nor biological differences between AS patients with and without microangiopathy. Capillaroscopy abnormalities seem frequent in AS and may be secondary to an immune complex mechanism.

Cutaneous vasculitis and IgA glomerulonephritis in ankylosing spondylitis

Two patients with ankylosing spondylitis were found to have IgA nephropathy and leucocytoclastic cutaneous vasculitis. Immunofluorescence showed perivascular deposition of IgA in the skin of one patient and in the mesangium of both patients. Such an association has been reported only once before. This supports the concept of abnormal IgA immune stimulation in the pathogenesis of ankylosing spondylitis.

Altered production of IgE and IgA induced by IL-4 in peripheral blood mononuclear cells from patients with IgA nephropathy

In order to elucidate the factors responsible for altered immunoglobulin production in patients with IgA nephropathy (IgAN), the in vitro effects of IL-4 and interferon-gamma (IFN-gamma) on the synthesis of IgE and IgA by peripheral blood mononuclear cells (PBMC) were studied. Spontaneous IgE and IgA synthesis by PBMC was significantly increased in patients with IgA nephropathy compared with controls. The maximum amounts of IgA and IgE synthesis by PBMC after stimulation with IL-4 were almost the same both in patients with IgAN and in controls. The enhancement rate of IL-4-induced IgE and IgA synthesis was significantly lower in IgAN than in the controls, suggesting in vivo preactivation of PBMC in IgAN patients. IFN-gamma suppressed IgA and IgE synthesis by PBMC from IgAN patients as well as controls. However, the suppressive effect on IgE synthesis was less prominent in patients with IgAN. These results suggested that altered IL-4 action might be involved in the development of IgA nephropathy.

Immune complexes in ankylosing spondylitis

Immune complexes have been reported in ankylosing spondylitis (AS) and may implicate infectious agents. Serum samples from 49 patients with AS were assayed for immune complexes by polyethylene glycol precipitation, followed by radial immunodiffusion and pepsinogen binding immunoassay. Both methods showed increases in IgA containing immune complexes, which correlated with serum IgA and with IgA rheumatoid factor concentrations, but did not show increases in other immune complex components. Increased immune complexes were associated with peripheral joint synovitis, but showed no correlation with other clinical or laboratory indices of disease activity. Immune complexes from nine AS serum samples and one AS synovial fluid were electrophoretically separated then probed with anti-Klebsiella pneumoniae, but AS specific antigens were not identified. This study did not suggest a major role for immune complexes in AS without peripheral disease, nor provide serological evidence for the involvement of klebsiella antigens.

IgA nephritis in a child with human immunodeficiency virus: a unique form of human immunodeficiency virus-associated nephropathy?

A 9-year-old boy is presented who was antibody positive for human immunodeficiency virus (HIV) and who had recurrent episodes of gross hematuria. Renal biopsy revealed findings typical of IgA nephropathy but also showed electron-microscopic abnormalities seen with HIV-associated nephropathy. In addition, IgA antibodies to multiple HIV proteins were detected in serum by Western blot analysis, and circulating immune complexes of the IgA class were present. Although HIV-associated nephropathy and IgA nephropathy are thought to be distinct conditions, five adults with a similar combination of findings have been reported, and our patient adds to the evidence for a link between these two entities in some patients. We propose that the histological parallels between the conditions may merely represent the limited renal responses available to multiple types of injuries, and we support the attempts underway to probe renal tissue for the HIV genome.

Adult Still's disease and mesangial glomerulonephritis. Report of two cases

Two patients with adult Still's disease and abnormal urinalysis underwent kidney biopsy 2 to 21 years after onset of the disease. Unexpectedly, mesangial glomerulonephritis was discovered. Even if a fortuitous association could not be excluded, the real prevalence of glomerular involvement in ASD should be determined by further studies in view of a potential immune complex pathogenesis of this condition.

IgA nephropathy associated with ankylosing spondylitis: occurrence in women as well as in men

Two patients (one male, one female) with ankylosing spondylitis (AS) and IgA nephropathy are described. The female patient is the first reported case to have AS and IgA nephropathy concurrently. Contrary to previously reported cases, her renal manifestation preceded her rheumatic symptoms. It is suggested that women with IgA nephropathy and AS may be overlooked as the severity of spondylitis and joint involvement is less than in men.

Relation of microscopic haematuria in ankylosing spondylitis to circulating IgA containing immune complexes

Ankylosing spondylitis (AS) is associated with IgA nephropathy. To study the pathogenetic mechanism of this association the presence of haematuria and circulating IgA containing immune complexes (IgA ICs) in 70 patients with AS was determined. In this retrospective study haematuria was present in 15 patients and 25 patients had IgA ICs. Circulating IgA ICs were shown in 9/15 (60%) of the patients with haematuria and in 16/55 (29%) of those without haematuria. These results suggest that IgA ICs in patients with ankylosing spondylitis have a pathogenetic role in causing IgA nephropathy.

Analysis of serum and synovial fluid IgA in Reiter's syndrome and reactive arthritis

The presumed antecedent infection which precedes Reiter's syndrome and reactive arthritis is frequently across a mucosal surface, and IgA immune responses may play a role in this process. Twelve of 29 patients with these conditions demonstrated elevation in serum IgA levels, and serum IgA levels in the postdysentery group (mean 3.21 g/liter +/- 1.27) were higher (P less than 0.01) than those in the posturethritis group (mean 2.40 g/liter +/- 0.80). In 10 of the 12 patients, IgA was the only immunoglobulin increased. There was no evidence of activation of complement in serum or synovial fluid. Using a complement-dependent assay, we were unable to demonstrate circulating IgA immune complexes. Sucrose density gradient ultracentrifugation analysis was used to assess IgA immune complexes in a non-complement-dependent manner. IgA of 11s was in fact demonstrated by this technique but appeared to be polymeric IgA on the basis of specific binding of secretory component and resistance to acid dissociation. IgA rheumatoid factor was not present. Synovial fluid revealed levels of polymeric IgA higher (mean 56.7% +/- 12.9) than did serum (23.7% +/- 13.9, P less than 0.001) despite higher levels of total IgA in serum than in synovial fluid (synovial fluid:serum ratio of IgA, mean 0.53 +/- 0.11). Although elevation in serum IgA in postdysenteric arthropathies suggests mucosal acquisition of antigen, the study does not implicate IgA circulating immune complexes in the pathogenesis of these diseases.

Renal affection in patients with ankylosing spondylitis and psoriatic arthritis

In a retrospective study of 148 patients with well-defined ankylosing spondylitis (AS), psoriatic arthritis (PSA) or reactive arthritis (ReA) an 11% prevalence of idiopathic hematuria, proteinuria, or cylinduria was found in the former two groups. None of the patients with ReA had unexplained pathological urinary findings. Such findings were associated with raised ESR and presence of peripheral arthritis in AS and with the duration of disease in PSA. No patient lacking sacroiliitis showed pathological urinary findings. We believe that such findings may reflect nephropathy associated with AS and PSA.

Circulating yersinia specific immune complexes after acute yersiniosis: a follow up study of patients with and without reactive arthritis

The occurrence of immune complexes (ICs) containing Yersinia enterocolitica antigen and immunoglobulin was studied in 216 serum samples from 51 patients with recent yersiniosis at an early stage of the disease and during a follow up of two to 12 months. Twenty eight of the patients developed reactive arthritis, 23 recovered from the infection without any complications. An enzyme linked immunosorbent assay (ELISA) recently developed for detection of ICs containing yersinia antigen(s) and IgM, IgG, or IgA was applied. During the first two months after onset of the infection yersinia specific IgM complexes were demonstrated in higher concentrations in patients with arthritis than in those not developing this postinfection complication (p less than 0.02). The difference in the occurrence of IgM complexes between the two groups decreased with time. Yersinia specific IgA complexes were demonstrable in four patients with arthritis and in none of the non-arthritic patients. Yersinia specific IgG complexes were occasionally present in both patient groups. Altogether, more than eight months after onset of the infection yersinia specific ICs were detected in six arthritic and two non-arthritic patients, suggesting that in certain individuals yersiniae may hide after the initial infection for prolonged periods.

Autointoxication revisited

The pustular dermatitis associated with small bowel bypass surgery and the cutaneous manifestations of inflammatory bowel disease are well known and generally assumed to be due to the absorption of microbial antigens from the bowel. Monomeric serum IgA is assumed to originate in the gastrointestinal tract, and circulating IgA immune complexes, as seen in dermatitis herpetiformis, should make us suspicious of a gastrointestinal tract source. These circulating immune complexes and perhaps polyclonal increases in serum IgA may be the result of minor perturbations of mucosal permeability or the failure of locally produced dimeric serum IgA to inactivate bacterial or dietary antigens. Such disparate entities as Reiter's syndrome, psoriasis, pyoderma gangrenosum, and ankylosing spondylitis, as well as the pustular eruptions of Behçet's syndrome, pustular psoriasis, and lithium therapy, may share this common pathogenesis.

Absence of IgA nephropathy in patients with ankylosing spondylitis

In 40 patients with ankylosing spondylitis (AS) no evidence for IgA nephropathy was obtained. This conclusion was based on the absence of hematuria and on the inability to find an increased incidence of IgA-containing immunoglobulin deposits in skin biopsies. Increased Clq binding assay was only found in those AS patients with anterior uveitis. In 26% of the skin biopsies perivascular mononuclear cell infiltrates were observed, and immunoglobulin deposits were seen in 65%. These facts suggest that the immunologic system is involved in the pathogenesis of this disease.

Polymyositis associated with several immunological disorders

A case of polymyositis associated with scleroderma, adult coeliac disease, diabetes mellitus and IgA nephropathy is reported in a 33-year-old male.

Increased incidence of recurrent hematuria in ankylosing spondylitis: a possible association with IgA nephropathy

A retrospective analysis of our patients with ankylosing spondylitis revealed a 17.8% incidence of recurrent hematuria. Two of the five patients with recurrent hematuria had previously undergone renal biopsies showing a focal proliferative glomerulonephritis. The only specimen examined by immunofluorescent staining showed the typical changes of IgA nephropathy. A control group of patients with rheumatoid arthritis did not show recurrent hematuria. Recurrent hematuria may be a frequent occurrence in ankylosing spondylitis and may signify the presence of one of the glomerulonephritides such as IgA nephropathy.

Serum and secretory IgA immune response to Klebsiella pneumoniae in ankylosing spondylitis

Serum and salivary IgA antibodies to Klebsiella pneumoniae were estimated by enzyme-linked immunosorbent assay (ELISA) in 53 patients with ankylosing spondylitis (AS) and 30 healthy controls. The concentrations of total serum IgA, salivary secretory component (SC) and serum C-reactive protein (CRP) were also measured. In the serum of AS patients there was a positive correlation between Klebsiella IgA antibodies and the CRP. Salivary anti-Klebsiella IgA was elevated in 39% of AS patients although this was not associated with disease activity. Serum and secretory IgA antibodies to E. coli and Pseudomonas aeruginosa were similar in patients and controls irrespective of disease activity. We conclude that part of the increase in salivary and serum IgA in AS may be due to a specific immune response to Klebsiella in the gastrointestinal tract and that serum antibodies reflect more closely those events associated with active inflammatory disease.