Progression of immunoglobulin G4-related disease to systematic lupus erythematosus after gastric cancer surgery: A case report

RATIONALE

Immunoglobulin G4 related disease (IgG4-RD) rarely coexists with other autoimmune diseases, though we had a patient whose primary clinical problem was shifted from IgG4-RD to systemic lupus erythematosus (SLE) after gastrectomy. The present paper aimed to report pathological findings and clinical course of the patient.

PATIENT CONCERNS

The patient was a male aged 74 years old with gastric cancer characterized by the following symptoms: Raynaud phenomenon, polyarthralgia, and swollen parotid glands on both sides. Before gastrectomy, laboratory examination results showed renal dysfunction, hypocomplementemia, antinuclear antibodies (ANAs) positivity, and elevated serum IgG and IgG4 levels.

DIAGNOSIS

Based on postoperative renal biopsy showing severe plasma cell infiltration with tubulointerstitial fibrosclerosis, the patient was diagnosed with IgG4-RD. Despite significant improvement in renal function and reduction in parotid gland swelling during the postoperative follow-up period, after 7 months of the gastrectomy, anti-DNA antibody levels were increased and serositis was detected, which indicated the onset of SLE. IgG4-type ANA were also detected in the sera of the patient.

INTERVENTIONS

Treatment by oral prednisolone at 30 mg/day was initiated.

OUTCOMES

Pericardial fluid, pleural effusions, and thickening of the gallbladder wall improved after 3 months of treatment according to computed tomography.

LESSONS

This study presented a rare case of comorbidity, wherein the patient's primary problem progressed from IgG4-type ANA-positive IgG4-RD to SLE after excision of gastric cancer.

Early recurrence of active IgA nephropathy after kidney transplantation

IgA nephropathy (IgAN) is recurrent after transplantation; however, its time of recurrence is unpredictable. To date, factors influencing IgAN recurrence have not been elucidated. We present a case of a 23-year-old man with end-stage renal disease (ESRD) who underwent living-related ABO-identical pre-emptive kidney transplantation (PEKT) using his 57-year-old mother as a donor. IgAN started when the patient was 19 years old, and renal biopsy revealed the usual pathological findings of IgAN. In spite of steroid therapy including steroid pulse and tonsillectomy, the patient developed nephrotic syndrome and progressed to ESRD in 4 years. Protocol biopsy on day 19 following PEKT revealed active recurrent IgAN. Nephrotic-range proteinuria and mild deterioration of kidney function developed regardless of strong immunosuppressive therapy such as steroid pulse, double filtration plasmapheresis and rituximab. We report a case of refractory IgAN that recurred 19 days after transplantation. This case is considered of value to elucidate factors leading to active IgAN recurrence.

A case of recurrent light chain deposition disease after living-related renal transplantation - detailed process of the recurrence

A 53-yr-old woman with end-stage renal disease was admitted for renal transplantation (RTX). About a decade ago, she had presented with urinary abnormalities. Monoclonal IgA lambda was detected. Renal biopsy showed nodular glomerulosclerosis, and an immunohistochemical study for lambda was negative. Fibrillary glomerulonephritis was suggested as the most likely diagnosis. RTX was successfully performed, and graft function was stable for the first half year. Graft biopsy was performed at one yr post-transplant. Glomeruli showed nodular lesion similar to native kidney biopsy findings. Immunofluorescence microscopy (IF) indicated strong lambda staining along the glomerular basement membrane, the tubular basement membrane (TBM), and the peritubular capillary. The diagnosis of recurrent light chain deposition disease (LCDD) was confirmed. A series of biopsies are available to conduct studies on the recurrent process of LCDD. Light microscopy showed no remarkable changes up to six months post-RTX. However, the IF study revealed evident granular depositions of lambda along the TBM only at the one-h biopsy. Typical IF staining pattern of lambda and EDD compatible with LCDD were noted after six months post-transplant. This is the first case report that elucidated the details of the recurrent process of LCDD at one yr after the operation.

Is the volume of the parathyroid gland a predictor of Maxacalcitol response in advanced secondary hyperparathyroidism?

We evaluated the relationship between the volume of parathyroid glands estimated by ultrasonography (US) and response of 22-oxa calcitriol (Maxacalcitol, OCT) in patients with secondary hyperparathyroidism (2HPT) to evaluate whether the volume can be a predictor of the OCT response. Eleven institutes participated in this study. Ninety-four patients with advanced 2HPT were enrolled. The volume of the parathyroid glands were estimated by US before and 6 months after OCT treatment. The response of OCT treatment was classified into three groups (Group A: i-PTH < 300 pg/mL; Group B: 300 pg/mL < or = i-PTH < 500 pg/mL; Group C: i-PTH > or = 500 pg/mL). Forty-eight patients were in Group A, 28 patients in Group B, and 18 patients in Group C. The PTH levels at the beginning and 6 months were 458.3-199.1 pg/mL (P < 0.0001) in Group A, 524.6-403.2 pg/mL (P = 0.007) in Group B and 736.7-613.6 pg/mL (ns) in Group C, respectively. The volume of the largest gland in Group B was significantly larger than that in Group A (96.2 vs. 343.2 mm3: P < 0.001). Clinical factors affecting response of OCT was evaluated by logistic regression analysis and only the volume of the largest gland was a significant factor. In the patients whose volume was less than 300 mm3, the OCT response was significantly effective. We conclude that the glandular volume of the largest parathyroid gland estimated by US can be a useful factor to predict the OCT response in patients with moderate or severe renal HPT.

[Three cases of severe hyponatremia under taking selective serotonin reuptake inhibitor (SSRI)]

The association between selective serotonin reuptake inhibitors(SSRIs) and hyponatremia has been documented throughout the world. In Japan, since SSRIs have recently come into use for patients with depression, there are only a few reports of hyponatremia associated with SSRIs. We present here three cases of the syndrome of inappropriate secretion of antidiuretic hormone(SIADH) associated with the administration of fluvoxamine for depression. They were admitted to our hospital because of deep coma, and revealed severe hyponatremia. Their serum sodium levels were 103-112 mEq/l, serum osmolalities were 227-241 mmol/kg, urine sodium levels were 38-107 mEq/l, and urine osmolalities were 352-781 mmol/kg. These patients were started on fluvoxamine 3 days-3 months previously. The diagnosis of SIADH in these patients was made based on hyponatremia, and low serum and high urine osmolalities. The fluvoxamine treatment was discontinued, and hypertonic saline was infused. Their serum sodium levels and osmolalities were subsequently normalized. None of the other known causes of hyponatremia, including diuretic therapy, tumors, and respiratory and central nervous system diseases, were present. High plasma AVP levels observed in the two cases suggest that SSRIs stimulate AVP secretion, thereby causing SIADH. Many reports have shown that people older than 70 years were at a particularly high risk of developing hyponatremia when SSRIs were used. In the future, since the use of SSRIs will be increasing, the water and electrolyte balance of elderly patients should be monitored carefully during SSRIs therapy.

[A case of non-Hodgkin's lymphoma presenting with acute renal failure diagnosed by renal biopsy]

We report a case of non-Hodgkin's lymphoma (NHL) presenting with acute renal failure. A-56-year-old male was admitted to our hospital on October, 1997 with fever and renal dysfunction. Physical examination showed no abnormality except for hepatomegaly. Body surface lymphadenopathy was not observed. Computed tomography (CT) of the abdomen showed markedly enlarged kidneys bilaterally and a mass of soft tissue density, which was considered as a swelling lymph node, around the aortic artery. The renal biopsy revealed parenchymal involvement of the NHL cells without normal tubulo-interstitial structure, but the glomeruli were almost intact. Our case rapidly fell into oliguria and acute renal failure, hence needed hemodialysis. After chemotherapy was performed, his renal function gradually improved and the kidney became smaller on subsequent CT. Unfortunately, the patient happened to suffer from methicillin-resistant staphylococcus aureus (MRSA) infection in a neutropenic state and died. Necropsy revealed recovery of the renal interstitium without residual NHL cells. Renal lymphoma without any other organ or nodal involvement is a rare type of NHL, which considered primary renal lymphoma (PRL). However, we believe this case to have been a result of lymphomatous infiltration of the kidneys in disseminated lymphoma.

[A case of MPO-ANCA-related vasculitis that recurred as gastrointestinal bleeding and presented difficulty in treatment]

A 54-year-old man, who had been diagnosed as having MPO-ANCA-related glomerulonephritis in 1993, developed severe anemia and was admitted to our hospital on October, 1997. Endoscopic examination of the upper gastrointestinal tract revealed melena due to duodenal ulcer (Dieulafoy type). The level of ANCA titer was elevated considerably (640 EU), but otherwise there was no evidence of systemic vasculitis activation such as fever, arthralgia, skin eruption, renal insufficiency, and rise in C reactive protein. A renal biopsy showed neither crescentic formation nor necrosis of glomerulus. Subsequently he developed hematochezia and renal dysfunction rapidly progressed thereafter. Angiographical examination of superior mesenteric artery revealed that the bleeding was responsible for the lesion of the small intestine, probably the ileum. In spite of TAE (transarterial embolization) he had recurrence of severe hematochezia three days later. Partial ileotomy was performed and progression of the anemia was stopped. Multiple ulcer was found in the resected ileum. The small arteries in the submucosa at the ulceration showed fibrinoid necrosis of the vessel walls. These findings suggested that ANCA-related vasculitis had relapsed. The patient received methylprednisolone pulse therapy, followed by oral administration of prednisolone after the operation. Both serum levels of creatinine and MPO-ANCA gradually decreased after the initiation of treatment. However, 24 days later, he suddenly manifested severe abdominal pain, and was diagnosed as having perforation of the stomach or duodenum. Due to supportive therapy and reduction of the steroid dose, peritonitis subsided, but symptoms caused by systemic vasculitis developed. Later raised the dose of steroid suppressed the activity of systemic vasculitis. In this case, elevation of the ANCA titer demonstrated recurrence of MPO-ANCA-related vasculitis as gastrointestinal bleeding.

Evaluation of glomerular lesion and abnormal urinary findings in OLETF rats resulting from a long-term diabetic state

Otsuka Long-Evans Tokushima Fatty (OLETF) rats have been established as an animal model in which non-insulin-dependent diabetes mellitus develops spontaneously. We examined the renal histopathology and the urinary findings serially in OLETF rats and compared these findings with findings in age-matched Long-Evans Tokushima Otsuka (LETO) rats as a control strain. OLETF rats showed higher blood glucose levels than did LETO rats from 18 weeks of age, and hemoglobin A1c levels became higher in OLETF rats than in LETO rats from 22 weeks of age. Accompanying the development of hyperglycemia was an increase in the amount of albuminuria in OLETF rats from 18 weeks of age. The initial histopathologic change found in OLETF rats was an increase in glomerular area, and mesangial expansion started to develop from 22 weeks of age. Mesangial lesions progressed to mesangial sclerosis, and exudative lesions were found in OLETF rats from 36 weeks of age. The anionic charge of glomerular basement membrane (GBM), measured by polyethyleneimine grain density, demonstrated that the lower grain density in OLETF rats when compared with that in LETO rats became more evident with an increase in the amount of albuminuria. Therefore, the defect in the charge-selective property found in OLETF rats might be one of the causes of albuminuria. The GBM became thickened in elderly OLETF rats as compared with that in age-matched LETO rats. Disturbances in the selectivity of urinary protein, as determined by the clearance ratio of immunoglobulin G to transferrin, were found to accompany the thickening of GBM in OLETF rats. We consider that both the loss of the charge-selective property and massive albuminuria might be the causes of GBM thickening, through a clogging mechanism, and that GBM thickening might in turn produce the loss of size selectivity. Given these findings, we consider the OLETF strain of rats to be an interesting animal model for studying the relationship between diabetes and renal involvement, because the glomerular abnormalities and massive albuminuria found in OLETF rats were results of a long-term diabetic state.