Acute Granulomatous Interstitial Nephritis Research Articles

Granulomatous Acute Interstitial Nephritis Revealing Multisystem Sarcoidosis Associated with Thyroiditis and Cushingoid Syndrome: Report of a Case and Review of the Literature

Introduction: Sarcoidosis can present with acute renal failure (ARF) due to granulomatous interstitial nephritis (GIN). We report the case of granulomatous acute renal failure (ARF) revealing multisystemic sarcoidosis in the nephrology department of the Aristide Le Dantec hospital in Dakar. Observation: Mrs. kD aged 54 with a past history of high blood pressure for 22 years, a multi nodular euthyroid goiter, referred to the nephrology department for impaired renal function. The clinical examination revealed at entry, deterioration in the general condition with weight loss and non-selective anorexia. Clinical anemia was also noted. The clinical examination also revealed Cushingoid syndrome and dry mouth syndrome. On biology, the blood count showed bicytopenia with anemia at 10.9 g/dl and leukopenia at 2620/mm3. There was an impairment of renal function with creatinine at 139.2 mg/l and blood urea at 1.76 g/l. The renal ultrasound became normal. Cervical ultrasound showed an aspect of abscessed thyroiditis of the right lobe. Chest computed tomography (CT) showed bilateral hilar adenomegaly and a band of bilateral basal linear atelectasis. The renal biopsy showed glomeruli of subnormal structure, the interstitium is riddled with tuberculoid follicles formed of epithelioid and multinucleated histiocytes of the Langhans type. The diagnosis of granulomatous acute interstitial nephritis revealing multisystemic sarcoidosis was kept. The evolution was favorable after 1 month of treatment with corticosteroid therapy with a clear improvement in renal function. Conclusion: Renal manifestations during sarcoidosis are rare. They can be indicative of the disease as in our patient. Renal biopsy is essential in any patient presenting with impaired renal function with extra-renal signs.

Tubulointerstitial nephritis and uveitis syndrome following meningitis and systemic lymphadenopathy with persistent Toxoplasma immunoglobulin M: a case report

BackgroundTubulointerstitial nephritis and uveitis syndrome is a rare lymphocyte-related oculorenal inflammatory disease presumed to be associated with drug use and infectious agents. Toxoplasma gondii is one of such pathogens that could exhibit encephalitis, meningitis, and uveitis in immunocompromised or in some immunocompetent individuals. If the immunoglobulin M of Toxoplasma is positive on screening, the interpretation of the result is not simple, especially when immunoglobulin M stays positive persistently.Case presentationA 34-year-old Asian male developed fever, headache, and lymphadenopathy with tenderness, which was initially diagnosed as meningitis. Antibiotics were started, and diclofenac sodium was used for the fever. Although his symptoms were alleviated in a week by the treatment, gradual decline in renal function was noted, prompting a renal biopsy that indicated acute granulomatous interstitial nephritis. A week later, tenderness in both eyes with blurred vision appeared and revealed iritis and keratic precipitations in both eyes; hence, the diagnosis of acute tubulointerstitial nephritis and bilateral uveitis syndrome was made. Toxoplasma gondii-specific immunoglobulin G and immunoglobulin M titers were both positive. Although we could not rule out recent infection of Toxoplasma gondii, which may cause uveitis initially, Toxoplasma immunoglobulin G avidity test indicated a distant infection, which allowed us to rule out meningitis and uveitis as responsible for the complication of recent Toxoplasma gondii infection. Drug-induced lymphocyte stimulation test, or lymphocyte transformation test of diclofenac sodium, was solely positive among the tested drugs. Uveitis was alleviated only with ophthalmic steroid, and renal function returned to normal without administration of systemic steroid.ConclusionsWe experienced a case of diclofenac-induced tubulointerstitial nephritis and uveitis syndrome. In ruling out infections, Toxoplasma immunoglobulin M was persistently positive, and Toxoplasma immunoglobulin G avidity test indicated a “distant” infection. From these two results, we ruled out recent infection. However, it should be noted that “distant” infection indicated by commercial immunoglobulin G avidity is still a multiplex profile consisting of reinfection, reactivation, and latent infection. Narrowing down the infection profile of Toxoplasma is challenging in some cases. Therefore, careful diagnosis and extended follow-up of such patients are needed.

Acute granulomatous interstitial nephritis in a patient with metastatic melanoma on targeted therapy with dabrafenib and trametinib—A case report

BackgroundCombination molecular targeted therapy with dabrafenib plus trametinib has been shown to improve progression‐free survival and overall survival in patients with BRAF V600 mutated unresectable or metastatic melanoma. In general, these agents are well tolerated. Kidney related adverse events are uncommon with only three case reports of acute interstitial nephritis and one case of a serious acute kidney injury. We report another case of interstitial nephritis related to these drugs.CaseA 37‐year‐old man diagnosed with metastatic melanoma (BRAF V600E mutation) who developed acute interstitial nephritis 5 years into his treatment with combination dabrafenib plus trametinib therapy. He presented with an asymptomatic acute kidney injury on routine surveillance pathology with a creatinine of 174 μmol/L (from baseline 80 μmol/L) and a corresponding estimated glomerular filtration rate (eGFR) of 42 ml/min/1.73 m2 (from a baseline >90 ml/min/1.73 m2) and microalbuminuria (albumin creatinine ratio [ACR] 8.5 mg/mmol). Renal biopsy revealed a granulomatous interstitial nephritis likely drug related. He was treated with prednisolone 1 mg/kg and ceased his targeted therapy with improvement in his renal function.ConclusionAlthough rare, recognition of acute interstitial nephritis, a possible serious adverse outcome due to dabrafenib and trametinib is important and needs to be incorporated into current Australian cancer therapy guidelines.

Clinical features of acute kidney injury in patients receiving dabrafenib and trametinib.

Our objective was to characterize the incidence, risk factors and clinical features of acute kidney injury (AKI) in patients receiving dabrafenib and trametinib. We performed a retrospective cohort study examining the kidney outcomes of patients in a large healthcare system who received dabrafenib/trametinib between 2010 and 2019. The primary outcome was AKI, defined as a 1.5-fold increase in serum creatinine from baseline within a 12-month study period. AKI severity and etiology was determined for each case by chart review. Logistic regression was used to evaluate baseline predictors of AKI. A total of 199 patients who received dabrafenib in our healthcare system from 2010 to 2019 were included in the analysis. Forty-two patients (21%) experienced AKI within 12 months; 10 patients (5% of the total cohort, 24% of AKI patients) experienced AKI occurring during a dabrafenib/trametinib-induced febrile syndrome characterized by fever, chills, gastrointestinal symptoms and elevated liver enzymes. Preexisting liver disease was the only significant predictor of AKI in the cohort. One patient had biopsy-proven granulomatous acute interstitial nephritis that resolved with corticosteroids. Oncologists and nephrologists should be aware that AKI is common after dabrafenib/trametinib and a substantial number of cases occur in the setting of treatment-induced pyrexia.

392 Acute Granulomatous Interstitial Nephritis in a Patient with Vancomycin-Induced DRESS Syndrome

392 Acute Granulomatous Interstitial Nephritis in a Patient with Vancomycin-Induced DRESS Syndrome

Acute granulomatous interstitial nephritis and ulcerative colitis: a case report and literature review

Tubulo-interstitial nephritis (TIN) in patients affected by inflammatory bowel disease, both ulcerative colitis and Crohn’s disease, is usually considered as drug-associated to aminosalicylate. We report a rare case of granulomatous active tubulo-interstitial nephritis in a young patient with a recent diagnosis of ulcerative colitis naïve to aminosalicylate treatment. The patient has been successfully treated with steroids administration. Our purpose is to sensitize that TIN should always to be considered in differential diagnosis an extra-intestinal manifestation of bowel disease.

Acute granulomatous interstitial nephritis and acute rejection in a kidney transplant recipient after zoledronic acid therapy – a case report and review of the literature

Acute granulomatous interstitial nephritis (AGIN) in native kidneys is most commonly linked to drugs. In allografts, it is a rare complication, and it occurs mostly with infections. Our case report presents AGIN with simultaneous acute cellular rejections and acute tubular necrosis in a kidney transplant patient 2weeks after intravenous application of zoledronic acid. A kidney biopsy showed signs of destructive AGIN with acute cellular rejection. After treatment with methylprednisolone pulses and immunosuppressive therapy modification, rebiopsy confirmed complete regression of AGIN with less intense persistent acute cellular rejection and acute tubular necrosis. Kidney function improved after glucocorticoid and intravenous immunoglobulin G therapy. To our knowledge, this is the first case of AGIN related to bisphosphonate zoledronate in a kidney transplant patient with consequent acute cellular rejection. In using intravenous zoledronate infusion in a kidney transplant recipient, we should be aware that it could potentially induce acute granulomatous tubulointerstitial nephritis and acute rejection. .

Granulomatous interstitial nephritis: a chameleon in a globalized world.

Two articles in this issue deal with granulomatous acute interstitial nephritis (GIN), a rare disorder seen in 0.5–0.9% of native and 0.6% of transplant renal biopsies [1]. In the first article, Agrawal and co-workers report 10 years of experience with GIN in a tertiary centre in India [2]. In contrast to the experience from Western countries, tuberculosis accounted for more than half of cases. The authors emphasize the challenge of making the diagnosis and recommend a high degree of suspicion [2]. In a second article, Shah and colleagues from the USA [3] review GIN and also highlight current challenges in describing the interesting case of a 69-year-old man with GIN ascribed to doxycycline in whom a positive quantiferon test was received and who eventually died from multi-organ failure. Without autopsy we will never know whether he actually had tuberculosis but their case also reminds us that even with sophisticated testing the cause of GIN remains unclear in a proportion of patients. In this comment, we reflect on both articles and provide some context with an emphasis on pathology and disease patterns worldwide, pitfalls and the diagnostic approach in clinic.

Kidney injuries related to ipilimumab

Monoclonal antibodies directed against the immune checkpoint protein cytotoxic T-lymphocyte antigen-4 (CTLA-4; CD152) have been investigated in metastatic melanoma and other cancers and have shown promising results. Inhibition of CTLA-4 characteristically induces well-known side effects called "immune-related adverse events" (irAEs). IrAEs mainly include colitis, dermatitis, hepatitis, endocrinopathies; uveitis, iridocyclitis, neuropathies, and inflammatory myopathy have occasionally been reported. Kidney involvement is rare. We report 2 cases of acute granulomatous interstitial nephritis and present, based on literature review, renal disorders related to Ipilimumab therapy. Autoimmune symptoms have to be carefully checked for patients treated with CTLA-4 inhibitors. In order to reduce the risk of sequelae, early recognition of irAEs and treatment initiation are crucial.

Isolated Renal Sarcoidosis Presenting with Granulomatous Interstitial Nephritis: A Case Report and Review of the Literature

Background: Sarcoidosis is a multi-system disorder characterized by noncaseating epitheloid granuloma in multiple organs. However, granulomatous interstitial nephritis in the absence of extrarenal renal lesions is very rare. Case presentation: A 64-year-old male presented with a weight loss of 10 kg and an increase in serum creatinine from 1.1 to 4.8 mg/dl over a 1-year period. At admission, no proteinuria or hematuria was found, although serum creatinine was 5.1 mg/dl and was associated with slight increases in serum angiotensin converting enzyme and calcium levels. Renal biopsy revealed granulomatous interstitial nephritis with noncaseating epitheloid cells. The patient was diagnosed with sarcoidosis, although no extrarenal sarcoid lesion was found. Oral prednisolone was effective, with normalization of serum creatinine levels 2 weeks later. A review of the literature showed that isolated granulomatous renal sarcoidsosis preferentially affected elderly males, and their serum angiotensin converting enzyme levels were normal or mildly increased in many cases. Conclusions: This paper describes a rare case of isolated renal sarcoidosis with acute granulomatous interstitial nephritis. This case and a relevant review of the literature demonstrate that sarcoid granulomatous interstitial nephritis should be considered as one of differential diagnoses in elderly male patients with suspected tubulointerstitial nephritis irrespective of angiotensin converting enzyme levels.

Oral bisphosphonate use in the elderly is not associated with acute kidney injury

Intravenous bisphosphonates can cause acute kidney injury; however, this risk was not found with oral bisphosphonates in randomized clinical trials with restrictive eligibility criteria. In order to provide complementary safety data, we studied the risk of acute kidney injury in a population-based cohort of 122,727 patients aged 66 years and older discharged from hospital following a new fragility fracture and no history of bisphosphonate use in the prior year. Bisphosphonate treatment was identified within 120 days after discharge and event rates were measured from 90 days of therapy initiation. The primary outcome was hospitalization with acute kidney injury with secondary outcomes of new nephrology consultation and, in a subset of patients with laboratory values, acute kidney injury was defined as an increase in serum creatinine. We identified 18,286 bisphosphonate users and 104,441 non-users with a mean age of 81 years. Of 5772 patients with laboratory values, 40% had chronic kidney disease (eGFR <60 ml/min per 1.73 m(2)). Overall, there was no statistically significant difference in the risk of acute kidney injury among bisphosphonate users compared to non-users (adjusted odds ratio 1.03), and no significant differences in other outcomes or in subgroups of patients with baseline chronic kidney disease. Thus, in this older population-based cohort, oral bisphosphonate use was not associated with acute kidney injury.

Mycobacterial-immune reconstitution inflammatory syndrome: a cause of acute interstitial nephritis during HIV infection

Kidney injury during HIV infection encompasses a wide variety of disorders, including acute interstitial nephritis. We report a case of acute granulomatous interstitial nephritis related to a mycobacterial-triggered immune reconstitution inflammatory syndrome (IRIS) in an HIV-infected patient. IRIS is an emerging health concern during HIV infection and should be considered in the diagnostic frame of acute renal failure during immune restoration.

Acute renal failure from nitrofurantoin-induced acute granulomatous interstitial nephritis

We report here a case of acute renal failure with nitrofurantoin-associated acute granulomatous interstitial nephritis (GIN), which was commenced as a long-term prophylactic agent for suspected recurrent urinary tract infections. Renal function improved with withdrawal of this agent and without the requirement of corticosteroids. All new medication changes should be held in suspicion as a cause of acute onset abnormalities in serum biochemistry.

A case of acute renal failure associated with diffuse infiltrative lymphocytosis syndrome

A 58-year-old African American man with an uncontrolled HIV infection presented to hospital with nephrotic syndrome and diffuse lymphadenopathy. The patient had been taking highly active antiretroviral therapy (HAART; lamivudine, abacavir, fosamprenavir and ritonavir) for 10 years. A renal biopsy showed acute granulomatous interstitial nephritis. Despite a negative tuberculin skin test, he was treated with antituberculosis drugs for 12 months without improvement of his renal profile. Two months after antituberculosis treatment was discontinued, the patient was readmitted to hospital because of acute renal failure. Corticosteroid therapy (prednisone) was started and resulted in a marked improvement in renal function. However, 18 months after steroids were discontinued, renal function declined dramatically. Furthermore, the patient had CD8+ lymphocytosis as well as interstitial tissue infiltration by CD8+ T lymphocytes. Physical examination, plasma HIV viral load, lymphocyte counts, urinalysis, tuberculin skin test, liver function tests, renal ultrasonography, human leukocyte antigen (HLA) typing, renal and minor salivary gland biopsies, ophthalmological examination, chest radiography and culture of bronchoalveolar lavage fluid. Acute granulomatous interstitial nephritis secondary to diffuse infiltrative lymphocytosis syndrome. HAART and prednisone.

Acute Granulomatous Interstitial Nephritis Secondary to Bisphosphonate Alendronate Sodium

Acute Granulomatous Interstitial Nephritis Secondary to Bisphosphonate Alendronate Sodium

Acute Granulomatous Interstitial Nephritis Secondary to Bisphosphonate Alendronate Sodium

Chronic lymphocytic leukemia (CLL) is the most common leukemia in the Western world and is characterized by a progressive accumulation of functionally incompetent monoclonal lymphocytes. Renal involvement has been described in CLL but is uncommon. Granulomatous interstitial nephritis is a rare but characteristic hallmark of certain diseases such as sarcoidosis and tuberculosis. These epithelial reactions have also been reported with medications, infections, inflammation, Wegener's granulomatosis, and jejunoileal bypass. We present a 74-year-old woman with a stage 0 chronic lymphocytic leukemia who developed acute renal failure following the initiation of alendronate. The renal biopsy revealed an acute granulomatous interstitial nephritis. Infectious and inflammatory etiologies were ruled out. Hemodialysis was required despite discontinuation of all medications. Partial recovery of renal function occurred after 6 weeks of prednisone therapy and cyclophosphamide. This report describes a unique case of acute granulomatous interstitial nephritis and leukemic cell kidney infiltration by CLL.

Acute granulomatous interstitial nephritis and colitis in anticonvulsant hypersensitivity syndrome associated with lamotrigine treatment

We present the case of a 17-year-old woman with a history of bipolar disorder, who developed a clinical syndrome manifested by fever, lymphadenopathy, skin rash, diarrhea, and acute renal failure requiring dialysis after the use of lamotrigine. Renal biopsy showed acute interstitial nephritis (AIN) with focal granulomas. Similarly, colonic biopsy specimens showed colitis and ileitis with non-necrotizing epithelioid granulomas. The patient had a complete recovery after withdrawal of the medication and steroid treatment. Although lamotrigine has been previously implicated in the development of anticonvulsant hypersensitivity syndrome, there have been no previous reports of acute granulomatous interstitial nephritis or colitis associated with the use of this drug.

Tubulointerstitial Nephritis Due to Vancomycin

Vancomycin was used to treat a patient with Staphylococcus aureus endocarditis. After 3 weeks of therapy, the patient developed a diffuse maculopapular rash, which resolved upon stopping the drug. Rechallenge with vancomycin several days later resulted in reappearance of the rash and rapid onset of acute anuric renal failure. Renal biopsy revealed acute granulomatous interstitial nephritis. This is the first report of biopsy-proven vancomycin-induced acute interstitial nephritis. Renal function should be monitored closely in patients receiving vancomycin therapy.