The nephrotic syndrome associated with secondary syphilis. An immune deposit disease

Kidney Pathology of Tropical and Nontropical Infectious Diseases in the Pediatric Population

OBJECTIVES

To review kidney pathology of tropical and nontropical infectious diseases in the pediatric population.

METHODS

We review 4 tropical and 2 nontropical infectious diseases that affect the kidneys of children in terms of their direct and indirect pathogenetic mechanism in inducing kidney damage.

RESULTS

We demonstrate clinical manifestations, pathogenesis, kidney pathology, and laboratory diagnostic methods for (1) renal cryptococcosis, which represents involvement of a pure direct pathway; (2) schistosomiasis and dengue fever as examples of dual direct and indirect pathways; and (3) congenital syphilis, visceral leishmaniasis, and Chagas disease, which represent indirect pathways.

CONCLUSIONS

Infective agents affect the kidneys of children mainly through indirect mechanisms, such as through immunological mechanisms as part of an antigenic response. A direct mechanism of kidney injury, however, is less known within the medical community simply because the direct mechanism is rarely encountered in nontropical countries. In some infectious diseases, both indirect and direct pathways are responsible in inducing 2 sets of morphologically separate kidney lesions.

Outcomes of infants born to pregnant women with syphilis: a nationwide study in Korea

BACKGROUND

Despite the expansion of antenatal syphilis screening programs, congenital syphilis (CS) remains a concern.

PURPOSE

This study aimed to analyze the manifestation and progress of CS, including treatment and follow-up, based on a nationwide study.

METHODS

From the Korean National Health Insurance Service database, a total of 548 infants were examined for CS during their first year of life from 2013 to 2018. Neurosyphilis and complications were investigated using the International Classification of Diseases-10 codes.

RESULTS

The birth rate of infants from mothers with syphilis was 2.8 per 10,000 live births for 5 years, which is not indicative of a decreasing trend. Overall, 148 infants were proven or highly probable or possible of having CS with treatment for 10 days; 66 infants were possible or less likely of having CS with only 1-day treatment. Jaundice (56 %) was common, followed by hearing impairment (14 %), renal disease (8 %), and mental retardation (8 %). Fourteen cases of neurosyphilis occurred. Infants with complications, including mental retardation, eye involvement, hearing impairment, or renal disease, were significantly associated with neurosyphilis (OR 8.49, P < 0.0001). Of 250 patients who received treatment, 92.8 % were treated with one medication: benzathine penicillin was used in 73 % of patients. Only four patients were re-treated due to treatment failure. In addition to the treponemal test, fluorescent treponemal antibody-absorption was the most utilized tool for diagnosis and follow-up.

CONCLUSIONS

Establishing standardized guidelines for the evaluation of CS, as well as the establishment of treatment regimens and follow up-plans for the disease, at a national level would help improve maternal and neonatal care and facilitate the eradication of CS in Korea.

Syphilis-Associated Acute Renal Failure and Hepatitis in the Setting of Human Immunodeficiency Virus Coinfection

Two individuals with human immunodeficiency virus presented in acute renal failure with nephrotic range proteinuria and were diagnosed with secondary syphilis. One of them also had elevated transaminases. Kidney biopsies revealed membranous nephropathy, a rare complication of secondary syphilis, in both cases. Normal hepatic and renal function were restored after treatment with penicillin.

Acute IgA-Dominant Glomerulonephritis Associated with Syphilis Infection in a Pregnant Teenager: A New Disease Association

Chronic kidney disease (CKD) is increasingly recognized as a risk factor in pregnancy; the differential diagnosis between CKD and preeclampsia (PE) may be of pivotal importance for pregnancy management and for early treatment of CKD. Acknowledging this connection may be useful also in a wider context, such as in the case reported in this paper, which for the first time describes an association between syphilis infection and IgA-dominant glomerulonephritis. A 16-year-old woman, referred to a general hospital due to a seizure, was found to be unknowingly pregnant. Based on hypertension and nephrotic proteinuria, she was initially diagnosed with PE. Immunological tests, as well as hepatitis and HIV tests showed negative results. However, secondary syphilis was diagnosed. In discordance with the PE diagnosis, urinalysis showed glomerular microhematuria with cellular casts. Proteinuria and hypertension did not remit after delivery, which was made via caesarean section, due to uncontrolled hypertension, at an estimated gestational age of 29 weeks. A male baby, weighing 1.1 kg (6.5 centile) was born. The baby was hospitalized in the neonatal intensive care unit, where he developed subependymal hemorrhage and thrombocytopenia, and neonatal syphilis was diagnosed. The mother underwent a kidney biopsy one week after delivery, leading to the diagnosis of IgA-dominant postinfectious glomerulonephritis. Mother and child were treated with support and antibiotic therapy, and were discharged in good clinical conditions four weeks later. Four months after delivery, the mother was normotensive without therapy, with normal kidney function and without hematuria or proteinuria. In conclusion, this case suggests that IgA-dominant postinfectious glomerulonephritis should be added to the spectrum of syphilis-associated glomerulonephritides, and underlines the need for a careful differential diagnosis with CKD in all cases of presumed PE. While diagnosis relies on kidney biopsy, urinary sediment, a simple and inexpensive test, can be the first step in distinguishing PE from other nephropathies.

Association of Exposure to Fine-Particulate Air Pollution and Acidic Gases with Incidence of Nephrotic Syndrome

Background: Air pollution has been associated with autoimmune diseases. Nephrotic syndrome is a clinical manifestation of immune-mediated glomerulopathy. However, the association between nephrotic syndrome and air pollution constituents remains unknown. We conducted this nationwide retrospective study to investigate the association between PM_2.5 and nephrotic syndrome. Methods: We used the Longitudinal Health Insurance Database (LHID) and the Taiwan Air Quality-Monitoring Database (TAQMD). We combined and stratified the LHID and the TAQMD data by residential areas of insurants linked to nearby air quality-monitoring stations. Air pollutant concentrations were grouped into four levels based on quartile. Univariable and multivariable Cox proportional hazard regression models were applied. Findings: Relative to Q1-level SO₂, subjects exposed to the Q4 level were associated with a 2.00-fold higher risk of nephrotic syndrome (adjusted HR = 2.00, 95% CI = 1.66⁻2.41). In NOx, relative to Q1 NOx concentrations, the adjusted HRs of nephrotic syndrome risk were 1.53 (95% CI = 1.23⁻1.91), 1.30 (95% CI = 1.03⁻1.65), and 2.08 (95% CI = 1.69⁻2.56) for Q2, Q3, and Q4 levels, respectively. The results revealed an increasing trend for nephrotic syndrome risk correlating with increasing levels of NO, NO₂, and PM_2.5 concentrations. Interpretation: High concentrations of PM_2.5, NO, NO₂, and SO₂ are associated with increased risk of nephrotic syndrome.

Congenital Syphilis Presenting with Only Nephrotic Syndrome: Reemergence of a Forgotten Disease

Syphilis infection has re-emerged after years of declining incidence. The prevalence of congenital syphilis (CS) has increased in Korea and other countries during the last few decades. Untreated infants develop symptoms such as rhinorrhea, anemia, jaundice, cutaneous lesions, hepatosplenomegaly, and pseudoparalysis within weeks or months. Significant renal disease is uncommon in CS, and clinical renal involvement varies from mild transient proteinuria to frank nephrosis. We report a 2-month-old infant with CS who presented with only nephrotic syndrome (NS). The previously healthy infant presented with NS and showed no other syphilitic manifestations. Remission of the NS was achieved with adequate penicillin treatment. No recurrence of proteinuria was observed during the 1 year of follow-up. Although rare, this long forgotten disease continues to affect pregnant women, resulting in prenatal or postnatal mortality. We still consider the possibility of syphilitic nephropathy and therefore serologic testing for congenital NS.

Simultaneous nephrotic syndrome and hepatitis in secondary syphilis: case report and review of the literature

A 66-year-old man presented with a penile ulcer, an acute clinical onset of nephrotic syndrome and hepatitis. Secondary syphilis was diagnosed on the basis of the history of rash and the result of strongly positive serological test for syphilis. A renal biopsy demonstrated membranous glomerulonephritis with subepithelial electron-dense deposits. After treatment with amoxicillin for 2 weeks, he achieved clinical recovery. It is important to recognize syphilis as a reversible cause of nephrotic syndrome and acute hepatitis because antibiotic therapy can result in complete remission.

A case of secondary syphilis demonstrating nephrotic syndrome and a solitary intrahepatic mass in a human immunodeficiency virus-1-infected patient

A 37-year-old, human immunodeficiency virus-1-infected Japanese man was referred because of nephrotic syndrome following emergence of generalized skin rash. Serological tests for syphilis turned out to be positive within ten months of the referral. Abdominal echography incidentally revealed a solitary intrahepatic mass without a detectable blood flow in segment 7. The patient's signs and symptoms, as well as the intrahepatic mass, resolved promptly after administration of amoxicillin. We consider that, in the present case, secondary syphilis caused the nephrotic syndrome and the intrahepatic mass, both of which have rarely been reported to date.

Early syphilitic hepatitis concomitant with nephrotic syndrome followed by acute kidney injury

Although acute hepatitis and nephrotic syndrome are commonly reported as complications of tertiary syphilis, nephrotic syndrome concomitant with hepatitis in early-stage syphilis is rare. Here, we describe the case of a 46-year-old male who was diagnosed with acute liver dysfunction and nephrotic syndrome after presenting with general malaise, and who subsequently developed acute kidney injury. Laboratory examination showed alkaline phosphatase had a greater magnitude of elevation compared to alanine aminotransferase, suggesting the possibility of syphilitic hepatitis. The rapid plasmin regain test and Treponema pallidum hemagglutination assay were positive, supporting the presence of a syphilis infection. Additionally, liver biopsy examination showed infiltration of inflammatory cells into the portal area and epithelioid cell granulomas. Moreover, kidney biopsy examination by both optical and electron microscopy showed a congestion of neutrophils in the capillary vessels, structural collapse of the tubules, and subepithelial deposits under the epithelium of the glomerular endothelial cells. These pathological changes were consistent with those reported previously for early syphilitic hepatitis and nephrotic syndrome in early-stage syphilis. All the symptoms, including liver and renal dysfunction, resolved after benzyl penicillin treatment was initiated. Hence, we believe early-stage syphilis should be included in the differential diagnosis of unknown liver damage and/or nephrosis.

The variety of clinical and histopathologic presentations of glomerulonephritis associated with latent syphilis

Glomerulonephritis is a well established but rather uncommon complication of latent secondary syphilis. We present three cases of glomerulopathies associated with luetic infection, observed and managed in our institutions in the past three years. They illustrate a variety of clinicopathologic presentations of this nephropathy, from acute nephrotic syndrome through membranous glomerulopathy up to rapidly progressive glomerulonephritis. Regardless of the clinical course and histologic type, they were all characterized by strongly positive results of serologic tests for syphilis. Our observations suggest the necessity of eliminating luetic infection in aetiologic considerations of each newly diagnosed case of nephrotic syndrome.

Nephrotic syndrome and hepatitis in early syphilis

A 54 year old man presented with features of acute hepatitis and the nephrotic syndrome. A diagnosis of active syphilis was only made by chance after extensive investigation. Syphilis should be considered in the differential diagnosis of both acute hepatitis and the nephrotic syndrome occurring separately as well as together.

Rabbit model of disseminated syphilis: immunoblot and immunohistologic evidence for a role of specific immune complexes in lesion pathogenesis

Circulating immune complexes (CIC) containing Treponema pallidum proteins have been preliminarily implicated as inducers of a neutrophilic vascular reaction in early human cutaneous lesions of secondary syphilis. To clarify the role of specific CIC in producing cutaneous and renal lesions, 12 rabbits were studied at the following intervals after induction of disseminated syphilis: 20 days (4 rabbits: biopsies of normal and lesional skin for direct immunofluorescence (IMF) for (IgG, IgM, IgA, Clq, C3, C4), fibrin, and T. pallidum proteins; routine histology; and immunoblots of serum for CIC containing T. pallidum proteins); 21 days (4 rabbits: as at 20 days without IMF for T. pallidum protein); 23 days (4 rabbits: as at 20 days without IMF); 30 days (same 12 rabbits restudied with routine histology of normal and lesional skin; kidneys from 4 rabbits removed for routine, IMF, and electron microscopy (EM). Treponemal polypeptide antigen (MW-87 kd) was demonstrated in CIC from rabbits. Routine cutaneous histology showed evolution of lesions from an early neutrophilic vascular reaction to the typical lymphoplasmacytic reaction. IMF showed vessel-based immunoreactants in 3 of the 4 rabbits tested at 20 days and 1 of 4 at 21 days, and T. pallidum proteins in 3 of 4 rabbits at 20 days. Routine histology, IMF, and EM studies of glomeruli showed glomerular abnormalities, but no evidence of immune deposits containing specific T. pallidum protein. Skin and kidney studies of 4 controls were all negative. These data indicate a role for specific immune complexes in the pathogenesis of cutaneous lesions in this rabbit model.

Unusual central chorioretinitis as the first manifestation of early secondary syphilis

Three young, otherwise healthy patients had a similar picture of unilateral central chorioretinitis associated with severe visual loss. Fluorescein angiography disclosed diffuse leakage under the neurosensory retina in the posterior pole, associated with multifocal areas of staining along the retinal vessels. Systemic examination showed a positive fluorescent treponemal antibody absorption test and a sharp increase in VDRL titers, indicative of active secondary syphilis. The patients responded dramatically to penicillin treatment, with visual recovery and resolution of the fundus lesions.

Renal disease and syphilis: a report of nephrotic syndrome with minimal change disease

A case of nephrotic syndrome and acute renal failure in a 74-year-old man with latent syphilis is described. A renal biopsy demonstrated focal global sclerosis in three of nine glomeruli, however, the remaining glomeruli revealed typical lesions of minimal change disease. Previous reports of renal involvement in syphilis have described membranous glomerulonephritis, mesangial and endothelial cell proliferative glomerulonephritis, and, recently, rapidly progressive glomerulonephritis. The proteinuria and renal failure resolved after penicillin therapy alone. This response strongly suggested that there was a causal relationship between the syphilis and the nephrotic syndrome. This is the first report of such a relationship.

Cutaneous secondary syphilis: preliminary immunohistopathologic support for a role for immune complexes in lesion pathogenesis

A circulating immune complex-mediated pathogenesis for lesions of secondary syphilis has been postulated. Textbook descriptions of a lymphoplasmacytic histopathologic picture have contradicted a role for circulating immune complexes in lesion pathogenesis. Four patients with early cutaneous lesions of secondary syphilis were studied. All four patients had serum Raji cell and/or Clq binding assay evidence for circulating immune complexes. Three patients showed a neutrophilic vascular reaction on histologic study of early lesions. The patients studied had immunofluorescence microscopic evidence of immunoreactant deposition in dermal blood vessels (4 hours) and/or a neutrophilic vascular reaction (24 hours) after intradermal histamine injection. Dieterle staining of lesional tissue from all patients showed the presence of treponemal organisms in dermal blood vessels. This new preliminary evidence adds some support to a circulating immune complex-mediated pathogenesis of cutaneous lesions in human secondary syphilis.

Secondary lesions in rabbits experimentally infected with Treponema pallidum

Thirty rabbits infected with 10(3) of either Nichols or Melbourne 1 strains of Treponema pallidum were observed for the development of secondary lesions, which appeared outside areas inoculated with viable treponemes. More rabbits infected with Melbourne 1 strain (eight of 15 rabbits) than were infected with the Nichols reference strain (three of 15 rabbits) developed secondary lesions. The mean (SD) incubation periods of secondary lesions were 52 (8) days for rabbits infected with Melbourne 1 and 56 (4) days for rabbits infected with Nichols strain. These mean incubation periods did not correlate with appreciably increased concentrations of immune complexes or glycosaminoglycans in the serum of infected rabbits.

Membranous glomerulonephritis

In a clinicopathological survey of idiopathic membranous glomerulonephritis (MGN) in 85 patients the predominance of the condition among men could be at least partly explained by an increased risk of exposure to organic solvents and heavy metals in the course of work. This may have implications for the advice given to these patients after MGN has been diagnosed. The selectivity of proteinuria could predict the likely outcome of the disease.

Rapidly progressive glomerulonephritis in a patient with syphilis. Identification of antitreponemal antibody and treponemal antigen in renal tissue

A 37-year-old man presented with biopsy-proved rapidly progressive glomerulonephritis and a strongly positive fluorescent treponemal antibody result. The patient was treated with hemodialysis, plasmapheresis, methylprednisolone, and penicillin, with rapid improvement and stabilization of renal function. Antibody was eluted from the frozen renal tissue and demonstrated a strongly positive reaction to the treponemal antigen when used in the fluorescent treponemal antibody test. In addition, when specific rabbit antitreponemal antiserum was applied to the frozen renal sections, there was a strongly positive reaction. Although syphilis has been associated with membranous glomerulopathy and post-infectious glomerulonephritis, this appears to be the first case of latent syphilis in which rapidly progressive glomerulonephritis has been identified. The presence within the glomeruli of treponemal antigen and antitreponemal antibody supports the association of these two entities.

Circulating immune complexes in experimental syphilis: identification of treponemal antigens and specific antibodies to treponemal antigens in isolated complexes

As a prelude to characterization of the host and treponemal antigens present in purified immune complexes from the sera of rabbits with disseminated syphilis, autoradiographic and immunoenzymatic analyses of solubilized extracts of Treponema pallidum, Treponema phagedenis biotype Reiter, and Treponema refringens were performed on electroblots of polypeptides first separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Electroblots of purified immune complexes were developed with the same panel of antisera so that protein profiles could be compared. Eight treponemal antigens were consistently present in isolated complexes; four of these cross-reacted with antisera prepared against avirulent treponemes. The average molecular weights of these antigens were 87,000, 76,000, 66,000, and 45,000. Antibodies dissociated from isolated immune complexes, when used for the development of T. pallidum electroblots, reacted with four antigens of comparable molecular weight. Antibodies to those polypeptides were also present in the sera of animals immunized with immune complexes. The demonstration of treponemal antigens in purified immune complexes convincingly argues that their occurrence in experimental syphilis is not merely due to tissue destruction and responses to endogenous host antigens.

Immune complex glomerulonephritis and amyloidosis in Schistosoma japonicum infected rabbits

Epidemiologically, the incidence of renal pathology in patients with chronic parasitic infections is higher than expected. In particular, schistosomiasis may have an association with renal failure. 24 New Zealand White rabbits were, therefore infected with 250 or 500 Schistosoma japonicum cercariae of the Philippine-Leyte strain and studied for eight months to determine if rabbits with long-term infections were suitable hosts for the study of schistosomal nephropathy. Clinical evidence for renal disease consisted of proteinuria, haematuria, and casts. Of the 18 surviving infected animals, six had trace amounts of protein in their urine, three had significant proteinuria ranging from 100 to 300 mg%, four exhibited haematuria and 14 were positive for the presence of proteinaceous cast formation. The clinical findings correlated with the histological data. Periodic open renal biopsies on a subgroup of the animals revealed no changes until about the sixth month. At eight months after infection, five (28%) of the 18 rabbits had amyloid deposits and 15 (83%) had some degree of renal change which included mild focal, diffuse intracapillary, and crescentic glomerulonephritis with mesangial and subendothelial complex trapping. Periodic-acid Schiff staining graphically demonstrated wire loops and tubular casts. Immunofluorescence showed that 15 (83%) of the infected animals exhibited diffuse mesangial and peripheral capillary wall deposition of IgG while 14 contained IgM (78%). The third component of complement was found in only five (28%) of the infected rabbits. Parasite antigen could not be detected in the glomeruli of any of the animals. Kidneys from age-matched controls were within normal limits. Electron microscopy of glomeruli from several animals demonstrated the presence of subendothelial and mesangial immune complex deposition similar to that seen in systemic lupus erythematosus. These findings show that schistosomiasis japonica in the rabbit offers an excellent model system for studying not only the renal pathology associated with human schistosomiasis but also the pathogenesis of amyloidosis which is a frequent sequela observed in a variety of chronic inflammatory infections.

Simultaneous hepatic and renal involvement in acute syphilis. Case report and review of the literature

An unusual case of simultaneously occurring acute syphilitic hepatic and renal disease is presented and a concise literature review of both the pathological and clinical findings in this disease is included. Hepatic and renal biopsies were useful in excluding other diagnostic possibilities and in establishing the correct diagnosis in the case presented.

Persistent serum immune complexes in syphilis

Serum immune complexes were estimated by a polyethylene glycol precipitation method in 51 patients with early syphilis. The immune complexes were increased in 41% of patients before treatment and decreased to normal limits in only 56% during treatment. The results of the specific antireponemal tests using dissolved immune complexes show that antibodies from the immune complexes are specific antibodies.

Thymoma and the nephrotic syndrome: a report of a case

A 48-year-old male presented with the nephrotic syndrome 3 years after resection and irradiation of a thymoma. Renal biopsy revealed membranous glomerulonephritis by electron microscopy. IgA, IgG, and C3 deposition were present in the glomerular basement membrane by immunofluorescence. There was no evidence of other autoimmune diseases or causes of the membranous glomerulonephritis. He has continued to have proteinuria and edema 1 year later.

Neuroblastoma presenting with the nephrotic syndrome

A case of neuroblastoma in a 4-yr-old boy presenting with the nephrotic syndrome is reported. Nether thrombosis nor stenosis of the renal veins and the inferior vena cava was present. Electron microscopy revealed lumps of subepithelial deposits as well as thickening and tortuosity of the glomerular basement membrane compatible with membranous nephropathy. It is postulated that deposition of neuroblastoma-associated immune complexes on the glomerular basement membrane-was responsible for the development of the nephrotic syndrome in this patient. Five pediatric cases of nephrotic syndrome associated with extrarenal neoplasia were collected from the world literature and are briefly discussed.

Circulating immune complexes in syphilitic nephropathy. A case report

A case of transient nephrotic syndrome caused by secondary syphilis is described. A renal biopsy was performed revealing subepithelial hump-like electron-dense deposits and fusion of epithelial foot-processes. Complement C1q-binding-activity and anticomplementarity were demonstrated in the blood, indicating the presence of circulating immune complexes. This strongly suggests that circulating immune complexes are significant in the immunopathogenesis of syphilitic nephropathy.

Demonstration by labeled treponemal antigen of specific antibodies in the tissue infiltrates of secondary syphilis

Specific antitreponemal antibodies have been demonstrated by immunofluorescence techniques in the lymphoplasmocytic infiltrates which characterize early symphilitic lesions. A purified suspension of Nichols strain Treponema pallidum was sonified and labeled with fluorescein isothiocyanate and applied to cryostat sections of 12 biopsy specimens from the cutaneous lesions of 11 patients with proven secondary syphilis, using a modified direct immunofluorescence procedure. Specimens from various inflammatory dermatoses processed similarly served as controls. Granular fluorescence was noted in the dermis in 9 of the 12 specimens corresponding to areas of heavy plasma cell infiltration and some fluorescence was found directly on plasma cells which were identified by subsequent hematoxylin and eosin staining. This fluorescence could be blocked by prior incubation of the sections with unlabeled sonified treponemal suspension. Control slides did not reveal any fluorescence. The use of labeled treponemal antigen may aid the tissue diagnosis of early syphilitic lesions which can mimic a variety of dermatological disorders.

The pathogenesis of experimental membranous glomerulonephritis induced with homologous nephritogenic tubular antigen

The renal tubular epithelial antigen (Tub-Ag) of rats was solublized by Pronase and purified by gel filtration and acrylamide gel electrophoresis. Purified Tub-Ag was a glycoprotein with S20,W value of 8.4. Utilizing radiolabeled Tug-Ag, a sensitive radioimmunoassay for Tub-Ag and homologous antibody (anti-Tub-Ag) was developed. Tub-Ag activity associated with a protein of the same molecular size was demonstrated in the serum, as well as in Pronase extracts of all the organs tested, including kidney, liver, lung, spleen, intestine, stomach, and heart. The physiochemical properties of the Tub-Ag of rats and its distribution were essentially the same as the Tub-Ag of humans, which had been found in immune deposits in the kidney of some patients with idiopathic membranous glomerulonephritis. Rats were immunized with the purified Tub-Ag emulsified in Freund's complete adjuvant and followed for Tub-Ag and anti-Tub-Ag in the serum, as well as for proteinuria and immunohistological changes in the kidney. Serum Tub-Ag dropped sharply after 20 days, when anti-Tub-Ag appeared in the circulation. Persistent, massive proteinuria appeared still later, more than 30 days after injection, when anti-Tub-Ag disappeared and Tub-Ag reappeared in the serum of some of those rats. In others, anti-Tub-Ag in the serum persisted throughout the observation period of 90 days. The pathology of the kidney of the rats with proteinuria was that of a typical membranous glomerulonephritis; thickening of glomerular capillary walls with granular deposits of gamma-globulin and Tub-Ag was observed. On the basis of these results, Tub-Ag in the serum, probably released from cellular membranes of various organs as a physiological metabolite, is considered to maintain the pathological process in the kidney by providing the antigen continuously to form immune complexes.

Nephrotic syndrome in vesicoureteric reflux

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The role of complement, immunoglobulin and bacterial antigen in coagulase-negative staphylococcal shunt nephritis

We describe three patients with arrested hydrocephalus in whom glomerulonephritis developed secondary to Staphylococcus epidermidis bacteremia from an infected ventriculoatrial shunt. Investigation of the immune-mediated renal disease associated with this chronic infection showed that (1) complement depletion during the acute phase of bacteremia and nephritis was predominantly via the classic pathway; (2) rheumatoid factor was associated with bacteremia, fever, proteinuria and low complement levels; (3) early complement components (C1q, C4, C3), immunoglobulin (predominantly immunoglobulin M [IgM], Staph. epidermidis antigen(s) and electron denxe subendothelial deposits were localized within the renal glomerulus; (4) C1q, and IgM derived from patient serums, were the most prominent in vitro immunoreactants to Staph. epidermidis cell walls; and (5) the causative organisms, Staph. epidermidis, shared common antigens with Staph. aureus, and antibody from patient serums cross reacted with extracts from both of these organisms.

Renal consequences of valvular heart disease

Three aspects of potential renal involvement in patients with valvular heart disease are discussed. These include (1) disturbances in renal salt and water handling and their implications with respect to diuretic management; (2) the hemodynamic effects of angiographic contrast agents with identification of potentially dangerous effects on the kidneys; and (3) the histologic patterns of bacterial endocarditis in the kidney and their similarity to those of immunologically mediated disease.

Immunopathogenesis of syphilitic glomerulonephritis. Elution of antitreponemal antibody from glomerular immune-complex deposits

A renal biopsy was performed on a patient with syphilitic glomerulonephritis characterized clinically by the acute onset of nephrosis that responded dramatically to penicillin therapy. Histologic, electron microscopical and immunohistochemical studies revealed an early membranous glomerulonephritis characterized by the presence of subepithelial basement-membrane deposits containing IgG and C3. The glomerular lesion, however, differed from that in the usual case of membranous nephropathy in that distinctive segmental lesions were present at the tubular poles of the glomeruli, and all the glomeruli exhibited mild proliferation of mesangial cells in association with the presence of IgM within mesangial areas. Antibody elution studies performed on the renal-biopsy specimen demonstrated the presence of antitreponemal antibody within the glomerular immune-complex deposits. This finding indicates that the glomerular injury occasionally complicating secondary syphilis is due to the deposition of treponemal antigen-antitreponemal antibody complexes.

Immunopathologic mechanisms of renal disease

Anti-GBM antibodies and glomerular deposition of circulating immune complexes are responsible for the immunopathogenesis of about 5% and 75% of human glomerulonephritides, respectively. Anti-GBM antibodies most frequently cause rapidly progressive glomerulonephritides, respectively in about half of the patients with pulmonary hemorrhage, the Goodpasture's syndrome. Immune complexes cause a wide variety of glomerulonephritides, including diffuse and focal proliferative, membranous, membranproliferative and rapidly progressive morphologic varieties often accompanied by nephrotic syndrome. Immune complexes cause a wide variety of glomerulonephritides, including diffuse and focal proliferative, membranous, membranoproliferative and rapidly progressive morphologic varieties often accompanied by nephrotic syndrome. Immunopathologic tubulo-interstitial renal injury can be caused by antibodies reacting with TBM or by deposition of immune complexes in tubulo-interstitial tissue. Immunofluorescence studies of renal tissue supplemented by detection of circulating anti-basement membrane antibodies and immune complexes are essential in differentiating the immunopathologic mechanisms of glomerular and tubular injury, and are necessary adjuncts in evaluating patients with glomerulo- and tubulo-interstitial nephritis.