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TdT-positive Infiltrate in Inflamed Pediatric Kidney: A Potential Diagnostic Pitfall. Am J Surg Pathol 2017; 41:706-716. [PMID: 28248816 DOI: 10.1097/pas.0000000000000828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We encountered a patient with infantile nephrotic syndrome associated with a dense interstitial inflammatory infiltrate and prominent extramedullary hematopoiesis. Immunohistochemical analysis revealed numerous terminal deoxynucleotidyl transferase (TdT)-positive cells, which may raise concern for lymphoblastic lymphoma. Thus, we further characterized a group of pediatric kidneys with inflammation. TdT-positive nuclei were quantitated, and dual immunostains for TdT/CD79a, TdT/CD3, and TdT/CD43 were performed in a subset of cases; flow cytometry was performed in 1 case. TdT-positive nuclei were present in inflamed pediatric kidneys in 40 of 42 patients. TdT counts (average of 3 maximal high-power fields) ranged from 1 to >200, with a mean of 47. The presence and number of TdT-positive nuclei showed a strong association with younger patient age. Extramedullary hematopoiesis was identified in 11/42 patients, all under the age of 1. The presence of extramedullary hematopoiesis did not correlate with TdT count (P=0.158). Dual immunostaining and flow cytometric analysis in 1 case showed weak expression of B-cell markers and favored normal precursor B cells. Although TdT is a common marker of lymphoblastic lymphoma, we have demonstrated that TdT-positive cells may be part of the inflammatory milieu in infant kidneys. Together with cytologic, architectural, and clinical features, these data can help to avoid misinterpretation of involvement by lymphoblastic lymphoma/leukemia.
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Alexander MP, Nasr SH, Kurtin PJ, Casey ET, Hernandez LPH, Fidler ME, Sethi S, Cornell LD. Renal extramedullary hematopoiesis: interstitial and glomerular pathology. Mod Pathol 2015; 28:1574-83. [PMID: 26449764 DOI: 10.1038/modpathol.2015.117] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 08/24/2015] [Accepted: 08/29/2015] [Indexed: 11/09/2022]
Abstract
Renal extramedullary hematopoiesis is rarely recognized in the antemortem setting. We identified 14 patients with renal extramedullary hematopoiesis on antemortem specimens from 1994 to 2015. The mean age was 68 years (range 47-87 years); males predominated (M:F=9:5). All presented with renal insufficiency, including five (36%) with acute kidney injury. The mean serum creatinine at biopsy was 2.9 mg/dl (range 1.2-7.3 mg/dl). All had proteinuria (mean 7.9 g/24 h; range 0.5-28; n=13), including 9 with ≥3 g/24 h. Renal extramedullary hematopoiesis appeared histologically as an interstitial infiltrate (n=12) and/or a perirenal infiltrate (n=3) or mass-like lesion (n=1). Five were misdiagnosed as interstitial nephritis. Concurrent glomerular disease was prevalent and included fibrillary-like glomerulonephritis (n=3), chronic thrombotic microangiopathy (n=5), focal segmental glomerulosclerosis (n=6), and diabetic glomerulosclerosis (n=2). All patients had an underlying hematologic malignancy: primary myelofibrosis in 9, myeloproliferative neoplasm not otherwise specified in 1, essential thrombocythemia in 1, polycythemia vera in 1, and plasma cell myeloma in 2. Clinical follow-up was available in 12 patients, mean of 29 months (range 4-120 months). In 10 patients for whom treatment history could be obtained, 9 were treated with chemotherapy, and 1 was treated with steroids. The mean creatinine at last follow-up was 2 mg/dl (range 1.2-3.9 mg/dl) (n=9). Ten patients died in the follow-up period from their underlying hematological disease and had persistent renal disease. The two remaining patients had persistent chronic kidney disease. Renal extramedullary hematopoiesis should be considered in the differential diagnosis of interstitial infiltrates, particularly in the presence of a glomerulopathy and a hematologic malignancy.
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Affiliation(s)
- Mariam P Alexander
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Samih H Nasr
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Paul J Kurtin
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Edward T Casey
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Loren P Herrera Hernandez
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mary E Fidler
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Ricci D, Mandreoli M, Valentino M, Sabattini E, Santoro A. Extramedullary haematopoiesis in the kidney. Clin Kidney J 2012; 5:143-145. [PMID: 29497517 PMCID: PMC5783215 DOI: 10.1093/ckj/sfs015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Extramedullary haematopoiesis (EMH) is the development of haematopoietic tissue outside the bone marrow and it most often occurs in the liver and spleen. Renal EMH is quite rare and there are very few case reports concerning the kidney. We describe two cases of ‘renal histologically documented EMH’ and, in particular, in the second of these two, the EMH tissue coexists with a clear cell renal carcinoma. Although rare, these clinical pictures raise some questions about the role of needle biopsy in the management of renal masses that present a diagnostic dilemma, especially in cases without involvement of other abdominal or intrathoracic organs.
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Affiliation(s)
- Davide Ricci
- Nephrology, Dialysis and Hypertension Unit, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marcora Mandreoli
- Nephrology, Dialysis and Hypertension Unit, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Massimo Valentino
- Radiology of Emergency Unit, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Elena Sabattini
- Hemo-Limphopathology Unit, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Antonio Santoro
- Nephrology, Dialysis and Hypertension Unit, Policlinico S. Orsola-Malpighi, Bologna, Italy
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