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Uzzo M, Kronbichler A, Alberici F, Bajema I. Nonlupus Full House Nephropathy: A Systematic Review. Clin J Am Soc Nephrol 2024; 19:743-754. [PMID: 38527995 PMCID: PMC11168831 DOI: 10.2215/cjn.0000000000000438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
Key Points Nonlupus full house nephropathy is a rare, complex entity: confusion arises by the low-quality evidence and the lack of consensus on nomenclature. This systematic review supports that systemic lupus erythematosus and nonlupus full house nephropathy are distinct clinical entities, with comparable outcomes. The identification of three pathogenetic categories provides further clues for a shared clinical and diagnostic approach to the disease. Background The presence of a full house pattern at immunofluorescence on kidney biopsy in a patient without clinical and laboratory features of systemic lupus erythematosus (SLE) has led to the descriptive term nonlupus full house nephropathy. This systematic review and meta-analysis focus on nonlupus full house nephropathy nomenclature, clinical findings, and outcomes. Methods In a reiterative process, all identified terms for nonlupus full house nephropathy and other medical subject headings terms were searched in PubMed. Out of 344 results, 57 records published between 1982 and 2022 were included in the analysis. Clinical data of single patients from different reports were collected. Patients were classified into three pathogenetic categories, which were compared according to baseline characteristics, treatments, and outcomes. Results Out of the 57 records, 61% were case reports. Nonlupus full house nephropathy was addressed with 17 different names. We identified 148 patients: 75 (51%) were men; median age 35 (23–58) years. Serum creatinine and proteinuria at onset were 1.4 (0.8–2.5) mg/dl and 5.7 (2.7–8.8) g/d. About half of patients achieved complete response. A causative agent was identified in 51 patients (44%), mainly infectious (41%). Secondary nonlupus full house nephropathy was mostly nonrelapsing with worse kidney function at onset compared with idiopathic disease (P = 0.001). Among the 57 patients (50%) with idiopathic nonlupus full house nephropathy, complete response was comparable between patients treated with immunosuppression and supportive therapy; however, proteinuria and creatinine at onset were higher in patients treated with immunosuppression (P = 0.09 and P = 0.07). The remaining 7 patients (6%) developed SLE after a median follow-up of 5.0 (1.9–9.0) years. Conclusions Our data support that SLE and nonlupus full house nephropathy are distinct clinical entities, with comparable outcomes. A small subset of patients develops SLE during follow-up. Nonlupus full house nephropathy is addressed by many different names in the literature. The identification of three pathogenetic categories provides further clues for the management of the disease.
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Affiliation(s)
- Martina Uzzo
- Department of Medicine and Surgery, University of Milano-Bicocca and ASST Monza, Monza, Italy
- Department of Pathology and Medical Biology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Ingeborg Bajema
- Department of Pathology and Medical Biology, University Medical Center, University of Groningen, Groningen, The Netherlands
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Li S, Bian Q. ANA-negative severe lupus-like presentation: Is it lupus or not? Clin Case Rep 2023; 11:e8145. [PMID: 37965182 PMCID: PMC10641295 DOI: 10.1002/ccr3.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/07/2023] [Accepted: 10/16/2023] [Indexed: 11/16/2023] Open
Abstract
Key Clinical Message Systemic lupus erythematosus is difficult to diagnose in patients who are antinuclear antibody (ANA) negative and lack typical clinical manifestations. For such patient who presented ANA-negative severe lupus-like manifestations, the diagnosis and treatment are a huge challenge. Histological findings may provide clues to diagnosis. Abstract Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease characterized by formation of autoantibodies to nuclear and cytoplasmic antigens. It was reported that a small subset of patients had typical clinical features of SLE with consistently negative antinuclear antibody (ANA), but such disease is usually mild and rarely involves multisystem. At present, there are no reports about severe lupus with ANA continued negative. Our report describes a 34-year-old Chinese woman who presented renal failure, multiple serous cavity effusion, and epilepsy, without malar rash, photosensitivity, lymphopenia, and arthritis. Further renal biopsy pathology revealed lupus-like nephritis. Autoantibodies, including ANA, antibodies against Smith and against double stranded DNA, were negative. Such a ANA negative and lack of typical clinical symptoms of SLE patient, but with severe lupus-like manifestations, whether it was lupus or not is worth discussing.
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Affiliation(s)
- Shuangxi Li
- Department of NephrologyChanghai Hospital, The Navy Medical UniversityShanghaiChina
| | - Qi Bian
- Department of NephrologyChanghai Hospital, The Navy Medical UniversityShanghaiChina
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Khan QA, khan T, Abdi P, Farkouh C, Anthony M, Hadi FA, Iram S. Diagnostic Dilemma of ANA-negative Pediatric Systemic Lupus Erythematosus in a South Asian Female. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231174321. [PMID: 37205006 PMCID: PMC10186573 DOI: 10.1177/11795476231174321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/20/2023] [Indexed: 05/21/2023]
Abstract
Background Systemic lupus erythematosus (SLE) is an autoimmune disorder affecting multiple organs with different degrees of severity. SLE is typically diagnosed based on the presence of antinuclear antibodies (ANA) in the serum. However, seronegative SLE is rare and is diagnosed by clinicians when the patient's ANA is negative but fulfills other diagnostic criteria. Case report We report a case of a 15-year-old South Asian female with SLE who had negative antinuclear antibodies yet displayed the typical clinical presentations of photosensitive maculopapular rash, joint pain, alopecia, anemia, and thrombocytopenia. Clinical evaluations in conjunction with lab results were used to establish a diagnosis of ANA-negative SLE. Conclusion ANA positivity is an entry criterion for SLE; rarely, cases of ANA-negative SLE may present. A typical clinical presentation may help determine the diagnosis in such a scenario. However, still, the physician should rule out immunodeficiency and other systemic illnesses before reaching a diagnosis of ANA-negative pediatric SLE.
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Affiliation(s)
- Qaisar Ali Khan
- Khyber Teaching Hospital MTI KTH,
Peshawar, Pakistan
- Qaisar Ali Khan, Khyber Teaching Hospital
MTI KTH, Peshawar 25120, Pakistan.
| | - Tehmina khan
- Khyber Teaching Hospital MTI KTH,
Peshawar, Pakistan
| | - Parsa Abdi
- Memorial University, St. Johns,
Newfoundland, Canada
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Roy S, Gupta R, Adapa S, Bose S, Garcha A. Hepatitis B–Associated Lupus-Like Glomerulonephritis Successfully Treated With Antiretroviral Drugs and Prednisone: A Case Report and Literature Review. J Investig Med High Impact Case Rep 2022; 10:23247096221086451. [PMID: 35491847 PMCID: PMC9067048 DOI: 10.1177/23247096221086451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Kidney involvement with hepatitis B virus is varied and mostly limited to nephrotic syndrome with membranous nephropathy and nephritic syndrome with membranous proliferative glomerulonephritis. Lupus nephritis is associated with nephritic or nephrotic range proteinuria with most common finding of sub-endothelial electron-dense deposits and immunological stain demonstrating full-house picture with all immunological marker staining. Our case discusses a young male patient presenting with rapidly worsening renal function along with proteinuria, found to be positive for both hepatitis B core antibody along with hepatitis B surface antibody plus positive anti-neutrophilic antibody but negative anti-double-stranded DNA. Kidney biopsy demonstrated hepatitis B–associated lupus-like glomerulonephritis. He responded successfully with antiretroviral therapy and high-dose prednisone. Patient did not need lupus-specific treatment and recovered with antiretroviral therapy only. Hepatitis B–associated lupus-like glomerulonephritis has rarely been reported and possess a diagnostic and therapeutic challenge to all nephrologists.
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Affiliation(s)
- Sasmit Roy
- University of Virginia, Charlottesville, USA
| | - Rohan Gupta
- Community Regional Medical Center, Fresno, CA, USA
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An Interesting Case of Nonlupus Full-House Nephropathy. Case Rep Nephrol 2022; 2021:9043003. [PMID: 34992890 PMCID: PMC8727156 DOI: 10.1155/2021/9043003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/17/2021] [Indexed: 11/30/2022] Open
Abstract
Full-house immunofluorescence and endothelial tubuloreticular inclusions are known as characteristic features of lupus nephritis. However, both features are not pathognomonic for lupus nephritis. A kidney biopsy specimen showing full-house immunofluorescence pattern in the absence of autoantibodies and classical clinical features of Systemic Lupus Erythematosus (SLE) is now considered as nonlupus full-house nephropathy (FHN). Nonlupus FHN may be idiopathic or due to other disease processes known as secondary nonlupus FHN. Here, we report the case of a 36-year-old female who presented with nephrotic proteinuria with bland urine sediment. Additional analyses revealed normal serum antinuclear antibody (ANA), normal anti-double-stranded DNA (anti-dsDNA) antibodies, and normal serum C3 and C4 levels. A renal biopsy showed a normal-appearing glomerulus without any proliferation or capillary wall thickening and widespread glomerular immune deposits (full-house effect; IgA, IgG, IgM, C3, and C1Q) on direct immunofluorescence. Renal electron microscopy showed diffuse effacement of visceral epithelial cell foot processes and mesangial electron dense deposits. The patient was diagnosed as nonlupus FHN. There is a controversial role of steroids and other immunosuppressive drugs in the treatment of nonlupus FHN patients, but our case patient responded favourably to steroid therapy. The term nonlupus FHN can be used as an umbrella term for patients who do not satisfy the clinical and serological criteria of SLE.
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Santos JE, Vicente R, Malvar B, Santos I, Coimbra M, Amoedo M, Pires C. Lupus-like nephritis with positive anti-neutrophil cytoplasmic antibodies and negative antinuclear antibodies. J Bras Nefrol 2022; 44:121-125. [PMID: 33107901 PMCID: PMC8943873 DOI: 10.1590/2175-8239-jbn-2020-0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022] Open
Abstract
Antineutrophil cytoplasmic antibodies (ANCAs) are associated with small vessel vasculitis but their prevalence is not rare in other immune diseases. In lupus nephritis (LN), their pathological role and clinical relevance have been the target of controversial views. We present a case of acute kidney injury and nephrotic syndrome in a young woman with diffuse global proliferative and membranous nephritis on her kidney biopsy, showing a full-house immunofluorescence pattern, very allusive of class IV + V LN, but lacking associated clinical criteria and laboratory findings to support the diagnosis of systemic lupus erythematosus (SLE). Furthermore, the patient presented with high titers of ANCA, steadily decreasing alongside the renal function and proteinuria improvements, with mycophenolate mofetil (MMF) and steroid treatment. The authors believe this is a case of lupus-like nephritis, in which ANCAs are immunological markers, although they are not directly involved in the pathogenesis.
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Affiliation(s)
| | - Rita Vicente
- Hospital Espírito Santo de Évora, Department of Nephrology, Évora, Portugal
| | - Beatriz Malvar
- Hospital Espírito Santo de Évora, Department of Nephrology, Évora, Portugal
| | - Iolanda Santos
- Hospital Espírito Santo de Évora, Department of Nephrology, Évora, Portugal
| | - Miguel Coimbra
- Hospital Espírito Santo de Évora, Department of Nephrology, Évora, Portugal
| | - Manuel Amoedo
- Hospital Espírito Santo de Évora, Department of Nephrology, Évora, Portugal
| | - Carlos Pires
- Hospital Espírito Santo de Évora, Department of Nephrology, Évora, Portugal
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Wani AS, Zahir Z, Gupta A, Agrawal V. Clinicopathological Pattern of Non-lupus Full House Nephropathy. Indian J Nephrol 2020; 30:301-306. [PMID: 33707816 PMCID: PMC7869643 DOI: 10.4103/ijn.ijn_91_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/03/2018] [Accepted: 07/28/2018] [Indexed: 12/16/2022] Open
Abstract
Background and Aims: Full-house immunofluorescence in a kidney biopsy is a common observation in lupus nephritis (LN) and was previously used synonymously with the diagnosis of LN. Though a minority of the patients will develop features suggestive of SLE during follow-up, a majority of the patients will continue without any clinical or serological evidence of systemic lupus erythematosus (SLE) over time. Our aim to conduct this study was to work up the clinicopathological spectrum of these “full-house” nephropathies (FHN) which were not due to lupus nephritis. Methods: A total of 6244 renal biopsies were evaluated at SGPGIMS Lucknow from January 2007 to December 2017 for full-house immunofluorescence. All those patients who had no clinical or serological evidence of SLE at the time of renal biopsy or at any time during follow up were included. Results: Among 498 patients with full house immunofluorescence, 81 patients had no clinical or serological evidence of SLE at the time of renal biopsy or at any time during follow up. The prevalence of non-lupus FHN in this study was 19.4%, and the major diagnoses were membranous nephropathy (25.9%), IgAN (22.2%), MPGN (14.8%), DPGN (12.3%), Crescentic GN (12.3%), Amyloidosis (8.6%), C1q nephropathy (3.7%). Conclusions: Full-house nephropathy (FHN), not otherwise suggestive of lupus nephritis, can also be found in a number of other conditions. Non-lupus full house nephropathy is an umbrella term for such cases which do not satisfy the standard criteria of SLE. This will prevent misclassifying these patients into SLE and further prevent them from unnecessary immunosuppression protocols.
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Affiliation(s)
- Asif S Wani
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Zafirah Zahir
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Gupta
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vinita Agrawal
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Non-lupus full house nephropathy in pediatrics: Case reports. ACTA ACUST UNITED AC 2020; 40:220-227. [PMID: 32673451 PMCID: PMC7505501 DOI: 10.7705/biomedica.4863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Indexed: 11/21/2022]
Abstract
Full house nephropathy is defined as the simultaneous detection of IgA, IgG, IgM, C3, and C1q deposits by immunofluorescence, usually indicating lupus nephritis. There are patients with this immunofluorescence pattern, but with negative autoantibody serology, which means they cannot be diagnosed with systemic lupus erythematosus. Patients presenting with full house nephropathy but no other criteria for lupus are diagnosed as having nonlupus full house nephropathy.
Here, we describe two cases: A male patient who debuted with rapidly progressive glomerulonephritis and a female patient with nephrotic syndrome. Both had negative autoantibody serology, findings in the renal biopsy of class IV lupus nephritis and afull house immunofluorescence pattern. Histological findings in non-lupus full house nephropathy are similar to those in lupus nephritis and, probably, similar physiopathological bases. However, prospective studies are needed to determine risk factors and the renal prognosis and to make suggestions for specific treatments.
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9
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Kudose S, Santoriello D, Bomback AS, Stokes MB, D'Agati VD, Markowitz GS. Sensitivity and Specificity of Pathologic Findings to Diagnose Lupus Nephritis. Clin J Am Soc Nephrol 2019; 14:1605-1615. [PMID: 31653670 PMCID: PMC6832038 DOI: 10.2215/cjn.01570219] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/11/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In 2012, the Systemic Lupus International Collaborating Clinics proposed that lupus nephritis, in the presence of positive ANA or anti-dsDNA antibody, is sufficient to diagnose SLE. However, this "stand-alone" kidney biopsy criterion is problematic because the ISN/RPS classification does not specifically define lupus nephritis. We investigated the combination of pathologic features with optimal sensitivity and specificity for the diagnosis of lupus nephritis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Three hundred consecutive biopsies with lupus nephritis and 560 contemporaneous biopsies with nonlupus glomerulopathies were compared. Lupus nephritis was diagnosed if there was a clinical diagnosis of SLE and kidney biopsy revealed findings compatible with lupus nephritis. The control group consisted of consecutives biopsies showing diverse glomerulopathies from patients without SLE, including IgA nephropathy, membranous glomerulopathy, pauci-immune glomerulonephritis, membranoproliferative glomerulonephritis (excluding C3 GN), and infection-related glomerulonephritis. Sensitivity and specificity of individual pathologic features and combinations of features were computed. RESULTS Five characteristic features of lupus nephritis were identified: "full-house" staining by immunofluorescence, intense C1q staining, extraglomerular deposits, combined subendothelial and subepithelial deposits, and endothelial tubuloreticular inclusions, each with sensitivity ranging from 0.68 to 0.80 and specificity from 0.8 to 0.96. The presence of at least two, three, or four of the five criteria had a sensitivity of 0.92, 0.8, and 0.66 for the diagnosis of lupus nephritis, and a specificity of 0.89, 0.95, and 0.98. CONCLUSIONS In conclusion, combinations of pathologic features can distinguish lupus nephritis from nonlupus glomerulopathies with high specificity and varying sensitivity. Even with stringent criteria, however, rare examples of nonlupus glomerulopathies may exhibit characteristic features of lupus nephritis.
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Affiliation(s)
| | | | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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10
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Smith BJ. Rheumatology Laboratory Tests. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Touzot M, Terrier CSP, Faguer S, Masson I, François H, Couzi L, Hummel A, Quellard N, Touchard G, Jourde-Chiche N, Goujon JM, Daugas E. Proliferative lupus nephritis in the absence of overt systemic lupus erythematosus: A historical study of 12 adult patients. Medicine (Baltimore) 2017; 96:e9017. [PMID: 29310419 PMCID: PMC5728820 DOI: 10.1097/md.0000000000009017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Severe lupus nephritis in the absence of systemic lupus erythematosus (SLE) is a rare condition with an unclear clinical presentation and outcome.We conducted a historical observational study of 12 adult (age >18 years) patients with biopsy-proven severe lupus nephritis or lupus-like nephritis without SLE immunological markers at diagnosis or during follow-up. Excluded were patients with chronic infections with HIV or hepatitis B or C; patients with a bacterial infectious disease; and patients with pure membranous nephropathy. Electron microscopy was retrospectively performed when the material was available. End points were the proportion of patients with a complete response (urine protein to creatinine ratio <0.5 g/day and a normal or near-normal eGFR), partial response (≥50% reduction in proteinuria to subnephrotic levels and a normal or near-normal eGFR), or nonresponse at 12 months or later after the initiation of the treatment.The study included 12 patients (66% female) with a median age of 36.5 years. At diagnosis, median creatinine and proteinuria levels were 1.21 mg/dL (range 0.5-11.6) and 7.5 g/day (1.4-26.7), respectively. Six patients had nephrotic syndrome and acute kidney injury. Renal biopsy examinations revealed class III or class IV A/C lupus nephritis in all cases. Electron microscopy was performed on samples from 5 patients. The results showed mesangial and subendothelial dense deposits consistent with LN in 4 cases, and a retrospective diagnosis of pseudo-amyloid fibrillary glomerulonephritis was made in 1 patient.Patients received immunosuppressive therapy consisting of induction therapy followed by maintenance therapy, similar to treatment for severe lupus nephritis. Remission was recorded in 10 patients at 12 months after the initiation of treatment. One patient reached end-stage renal disease. After a median follow-up of 24 months, 2 patients relapsed.Lupus nephritis in the absence of overt SLE is a nosological entity requiring careful etiological investigation, including systematic electron microscopy examination of renal biopsies to rule out fibrillary glomerulonephritis. In this series, most patients presented with severe glomerulonephritis, which was highly similar to lupus nephritis at presentation and in terms of response to immunosuppressive therapy.
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Affiliation(s)
| | | | - Stanislas Faguer
- Département de Néphrologie et Transplantation d’organes, Hôpital Rangueil, CHU de Toulouse
| | - Ingrid Masson
- Service de néphrologie, Service de néphrologie, CHU Saint-Etienne
| | - Hélène François
- Service de Médecine interne et immunologie clinique, CHU Bicêtre, Kremlin-Bicêtre
| | - Lionel Couzi
- Service de néphrologie-transplantation, CHU de Bordeaux, FHU ACRONYM, CNRS-UMR 5164 Immuno Concept
| | | | | | | | | | | | - Eric Daugas
- Service de néphrologie, CHU Bichat, AP-HP, INSERM U1199, Paris Diderot University and DHU FIRE, Paris, France
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12
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Maziad ASA, Torrealba J, Seikaly MG, Hassler JR, Hendricks AR. Renal-Limited "Lupus-Like" Nephritis: How Much of a Lupus? Case Rep Nephrol Dial 2017; 7:43-48. [PMID: 28612005 PMCID: PMC5465519 DOI: 10.1159/000475493] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/02/2017] [Indexed: 11/19/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by development of autoantibodies to nuclear and cytoplasmic antigens. A small subset of SLE patients who had the typical clinical features of SLE was reported to show persistently negative antinuclear antibody tests. Our report describes a 5-year-old male who presented with histopathological findings suggestive of lupus nephritis with no clinical signs or symptoms of SLE and negative autoantibodies. He was treated with corticosteroids, mycophenolate mofetil, and monthly intravenous cyclophosphamide. During the 2-year follow-up period, the proteinuria resolved and kidney function improved with continued negative autoantibody workup. This case presents a category of renal-limited “lupus-like” glomerulonephritis which can be challenging to treat and carries a poor prognosis.
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Affiliation(s)
- Asmaa S Abu Maziad
- aDivision of Nephrology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California, USA.,bDivision of Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jose Torrealba
- cDivision of Renal Pathology, Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mouin G Seikaly
- bDivision of Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jared R Hassler
- cDivision of Renal Pathology, Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Allen R Hendricks
- cDivision of Renal Pathology, Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Zaarour M, Weerasinghe C, Eter A, El-Sayegh S, El-Charabaty E. An Overlapping Case of Lupus Nephritis and IgG4-Related Kidney Disease. J Clin Med Res 2015; 7:575-81. [PMID: 26015827 PMCID: PMC4432904 DOI: 10.14740/jocmr2189w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 12/24/2022] Open
Abstract
We report a case of a 71-year-old Filipino female who was admitted to the hospital for abdominal pain, vomiting and diarrhea of 8 days duration. The patient was found to have marked acute kidney injury (AKI), which required hemodialysis in the next 3 days. Extensive workup revealed hematuria, subnephrotic range proteinuria, elevated anti-nuclear antibody (ANA) and elevated total immunoglobulin G (IgG) levels, with normal IgG4 and anti-dsDNA levels. On kidney biopsy, mild membranous glomerulonephritis was found, along with autoimmune tubulointerstitial nephritis (TIN) with a “full-house” pattern of immune deposits. These findings were suggestive of lupus interstitial nephritis. However, IgG4+ plasma cells were detected in the interstitium by immunostaining, favoring a diagnosis of IgG4-related kidney disease (IgG4-RKD). Our case highlights the difficulty in differentiating lupus nephritis (LN) from IgG4-RKD in some patients, raising the suspicion that these two entities can co-exist.
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Affiliation(s)
- Mazen Zaarour
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Chanudi Weerasinghe
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Ahmad Eter
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
| | - Suzanne El-Sayegh
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
| | - Elie El-Charabaty
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
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Bhobe MR, Tambe S, Jindal S, Jerajani HR. Rowell's Syndrome to ds-DNA Negative Lupus Nephritis: A Yet Unreported Progression. Indian J Dermatol 2015; 60:215. [PMID: 25814748 PMCID: PMC4372952 DOI: 10.4103/0019-5154.152604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Rowell's syndrome is now identified as a subtype of subacute lupus erythematosus (LE) with erythema multiforme-like skin lesions, positive serum rheumatoid factor, anti-Ro La positivity and speckled pattern of antinuclear antibodies. Here we describe a case of Rowell's syndrome in an 18-year-old female who was found to be ds-DNA negative, who later progressed to develop stage V lupus nephritis (LN) over a course of 4 months. Although extremely rare, most cases of LN are drug induced. Of only seven cases of non-drug induced LN with negative dsDNA, none had cutaneous involvement. Ours was a unique case of progression of Rowells syndrome to ds-DNA negative LN.
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Affiliation(s)
- Mayur R Bhobe
- Department of Skin and VD, MGM Medical College, Navi Mumbai, India
| | - Swagata Tambe
- Department of Skin and VD, MGM Medical College, Navi Mumbai, India
| | - Saurabh Jindal
- Department of Skin and VD, MGM Medical College, Navi Mumbai, India
| | - H R Jerajani
- Department of Skin and VD, MGM Medical College, Navi Mumbai, India
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Abdwani R, Abdalla E, El-Naggari M, Al Riyami M. Henoch-Schonlein purpura with lupus-like nephritis: an uncommon occurrence. Int J Rheum Dis 2014; 20:1853-1855. [PMID: 25302414 DOI: 10.1111/1756-185x.12461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Reem Abdwani
- Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Eiman Abdalla
- Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Mohamed El-Naggari
- Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Marwa Al Riyami
- Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman
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16
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Pirkle JL, Freedman BI, Fogo AB. Immune Complex Disease With a Lupus-like Pattern of Deposition in an Antinuclear Antibody–Negative Patient. Am J Kidney Dis 2013; 62:159-64. [DOI: 10.1053/j.ajkd.2013.02.353] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 02/14/2013] [Indexed: 11/11/2022]
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17
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Wallbach M, Gröne HJ, Kitze B, Müller GA, Koziolek MJ. Nephrotic Syndrome in a Multiple Sclerosis Patient Receiving Long-term Interferon Beta Therapy. Am J Kidney Dis 2013; 61:786-9. [DOI: 10.1053/j.ajkd.2012.11.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 11/19/2012] [Indexed: 11/11/2022]
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18
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Rousseau-Gagnon M, Riopel J, Desjardins A, Garceau D, Agharazii M, Desmeules S. Gemella sanguinis endocarditis with c-ANCA/anti-PR-3-associated immune complex necrotizing glomerulonephritis with a 'full-house' pattern on immunofluorescence microscopy. Clin Kidney J 2013; 6:300-4. [PMID: 26064489 PMCID: PMC4400477 DOI: 10.1093/ckj/sft030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/26/2013] [Indexed: 01/23/2023] Open
Abstract
A 67-year-old man was evaluated for haematuria, with a rising creatinine level from 88 to 906 µmol/L and positive c-anti-neutrophil cytoplasm antibody (ANCA)/anti-proteinase 3 (anti-PR3). A kidney biopsy revealed necrotizing glomerulonephritis with a ‘full-house’ pattern on immunofluorescence microscopy. Echocardiography and blood cultures growing Gemella sanguinis diagnosed endocarditis. Dialysis was required for a month. Three months later, following valve replacement, glucocorticoids and 2 months of antibiotic therapy, the creatinine level decreased to 62 µmol/L and c-ANCA/anti-PR3 disappeared. This first case of c-ANCA/anti-PR3 positive glomerulonephritis with a ‘full-house’ immunofluorescence pattern due to bacterial endocarditis underlines the importance of ruling out infection with ANCA positivity or kidney biopsy suggestive of lupus nephritis.
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Affiliation(s)
| | - Julie Riopel
- Service of Pathology , CHUQ-Hôtel-Dieu de Québec , Quebec , Canada
| | - Anne Desjardins
- Service of Infectious Diseases , CHUQ-Hôtel-Dieu de Québec , Quebec , Canada
| | | | - Mohsen Agharazii
- Service of Nephrology , CHUQ-Hôtel-Dieu de Québec , Quebec , Canada
| | - Simon Desmeules
- Service of Nephrology , CHUQ-Hôtel-Dieu de Québec , Quebec , Canada
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19
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Ruggiero B, Vivarelli M, Gianviti A, Benetti E, Peruzzi L, Barbano G, Corona F, Ventura G, Pecoraro C, Murer L, Ghiggeri GM, Pennesi M, Edefonti A, Coppo R, Emma F. Lupus nephritis in children and adolescents: results of the Italian Collaborative Study. Nephrol Dial Transplant 2013; 28:1487-96. [DOI: 10.1093/ndt/gfs589] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Yang HC, Hong MJ, Lim JH, Jang SA, Jeon SY, Yoo WH. A Case of ANA-negative, Anti-dsDNA Negative, and Anti-Ro/SSA Positive Membranous Lupus Nephropathy. JOURNAL OF RHEUMATIC DISEASES 2013. [DOI: 10.4078/jrd.2013.20.2.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hee-Chan Yang
- Division of Rheumatology, Department of Internal Medicine, Chonbuk National University Medical School and The Research Institute of Clinical Medicine, Jeonju, Korea
| | - Myong-Joo Hong
- Division of Rheumatology, Department of Internal Medicine, Chonbuk National University Medical School and The Research Institute of Clinical Medicine, Jeonju, Korea
| | - Jin-Han Lim
- Division of Rheumatology, Department of Internal Medicine, Chonbuk National University Medical School and The Research Institute of Clinical Medicine, Jeonju, Korea
| | - Seol-A Jang
- Division of Rheumatology, Department of Internal Medicine, Chonbuk National University Medical School and The Research Institute of Clinical Medicine, Jeonju, Korea
| | - So-Yeon Jeon
- Division of Rheumatology, Department of Internal Medicine, Chonbuk National University Medical School and The Research Institute of Clinical Medicine, Jeonju, Korea
| | - Wan-Hee Yoo
- Division of Rheumatology, Department of Internal Medicine, Chonbuk National University Medical School and The Research Institute of Clinical Medicine, Jeonju, Korea
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21
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Hobeika L, Srivastava M, Vo M, Philipneri MD, Brink DS, Wasi N, Lentine KL. Lupus-like glomerulonephritis: an autoimmune complication of hepatitis C infection. CEN Case Rep 2012; 1:29-33. [PMID: 28509148 DOI: 10.1007/s13730-012-0008-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 02/09/2012] [Indexed: 11/28/2022] Open
Abstract
Lupus-like glomerulnephritis in patients with negative lupus serologies and no extra-renal manifestations of lupus can create a diagnostic dilemma. We describe a 53-year-old gentleman with chronic hepatitis C virus (HCV) infection who presented with dialysis-requiring renal failure, renal histologic findings of "full-house" immunofluorescence label and tubuloreticular inclusions on electronic microscopy, but no extra-renal or laboratory signs of systemic lupus erythematosis. Attempted treatment with cyclophosphamide and corticosteroids was limited by cyclophosphamide hypersensitivity. The patient remained dialysis-dependent over 18 months of observation and did not develop extra-renal clinical or biological manifestations of lupus. Mimics of seronegative lupus with isolated renal involvement can include HCV-related autoimmunity. Treatment of acute glomerulonephritis may be similar initially, but other concerns in patients with HCV infection include excluding cryoglobulinemia, the potential impact of immunosuppression therapy on liver disease and consideration of subsequent use of antiviral therapy. Given the increasing prevalence of HCV globally, the recognition of extra-hepatic autoimmune manifestations of HCV infection will likely increase.
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Affiliation(s)
- Liliane Hobeika
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Monica Srivastava
- Division of Nephrology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Mai Vo
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Marie D Philipneri
- Division of Nephrology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - David S Brink
- Departments of Pathology and Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Nadia Wasi
- Division of Nephrology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Krista L Lentine
- Division of Nephrology, Saint Louis University School of Medicine, St. Louis, MO, USA. .,Center for Outcomes Research, Saint Louis University, 3545 Lafayette Avenue, Salus Center, St. Louis, MO, 63104, USA.
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22
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Dual anca positivity in a child with moyamoya-like cerebral vascular changes: an unusual presentation with sudden homonymous hemianopsia. Rheumatol Int 2011; 32:3295-8. [DOI: 10.1007/s00296-011-2064-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 08/10/2011] [Indexed: 10/17/2022]
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23
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Wen YK, Chen ML. Clinicopathological study of originally non-lupus "full-house" nephropathy. Ren Fail 2011; 32:1025-30. [PMID: 20863204 DOI: 10.3109/0886022x.2010.510614] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Glomerular "full-house" immunofluorescence staining commonly indicates lupus nephritis. However, some non-lupus nephropathy also can present with a "full-house" immunofluorescence pattern mimicking lupus nephritis. The goal of this study is to define the clinicopathological spectrum of originally non-lupus "full-house" nephropathy. METHODS Records of 24 patients with "full-house" nephropathy in the absence of clinical or serological evidence of systemic lupus erythematosus (SLE) at the time of renal biopsy were abstracted for demographics, clinical presentation, laboratory data, renal biopsy findings, and clinical follow-up. RESULTS The clinicopathological diagnoses included membranous glomerulonephritis (GN) (46%), IgA nephropathy (21%), membranoproliferative GN (12.5%), postinfectious GN (12.5%), C1q nephropathy (4%), and unclassified mesangial GN (4%). No one had endothelial tubuloreticular inclusions. One patient originally diagnosed as IgA nephropathy developed anti-DNA antibody and another one patient with membranous GN developed hypocomplementemia 8 months and 10 months after renal biopsy, respectively. The two patients also developed clinical symptoms of lupus subsequently. CONCLUSIONS There was a broad spectrum of glomerular histological findings in non-lupus "full-house" nephropathy. The possibility of "full-house" nephropathy preceding the emergence of overt systemic lupus erythematosus remained to be elucidated.
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Affiliation(s)
- Yao-Ko Wen
- Division of Nephrology, Changhua Christian Medical Center, Changhua, Taiwan.
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24
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L'Erario I, Frezzolini A, Ruggiero B, De Pità O, Emma F, Gianviti A. Usefulness of skin immunofluorescence for distinguishing SLE from SLE-like renal lesions: a pilot study. Pediatr Nephrol 2011; 26:77-83. [PMID: 20938690 DOI: 10.1007/s00467-010-1655-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 08/21/2010] [Accepted: 08/27/2010] [Indexed: 11/30/2022]
Abstract
Lupus nephritis (LN) may represent a diagnostic problem, particularly in pediatric patients that present with typical histological lesions but do not fulfill the American Rheumatism Association (ARA) criteria for the diagnosis of systemic lupus erythematosus (SLE). Based on the well-described deposition of immunoglobulins (Ig) and complement at the dermoepithelial junction in SLE, we hypothesized that skin biopsies may help in the diagnosis of LN. To test this hypothesis, we carried out a pilot study, performing a skin biopsy in 22 patients with LN and 13 patients with lupus-like lesions, regardless of the time elapsed from onset of renal disease. The latter group of patients was further divided into a purely renal group, designated as isolated full-house nephropathy (FHN), and a dubious cases group, presenting with additional clinical and biological features consistent with SLE but insufficient for diagnosing SLE. None of the 6 isolated FHN patients had positive skin immunofluorescence. Conversely, 5/7 patients in the dubious cases group (p<0.02) and 13/22 in the LN group (p<0.002) had positive staining for C1q, and 5/7 patients in the dubious cases group (p<0.02) and 16/22 patients in the LN group (p<0.001) had positive staining for IgM. No correlation was observed with the time elapsed from the initial diagnosis. These data suggest that skin biopsies may help distinguishing LN from isolated FHN. In addition, they identify an intermediate group of patients with evidence of systemic involvement despite the absence of a sufficient number of ARA criteria to be labeled as SLE.
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Affiliation(s)
- Ines L'Erario
- Department of Nephrology and Urology, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
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