Case Of Granulomatous Interstitial Nephritis Research Articles

Granulomatous interstitial nephritis in a patient with SARS-CoV-2 infection

BackgroundAcute kidney injury (AKI) associated with severe coronavirus disease 19 (COVID-19) is common and is a significant predictor of morbidity and mortality, especially when dialysis is required. Case reports and autopsy series have revealed that most patients with COVID-19 – associated acute kidney injury have evidence of acute tubular injury and necrosis - not unexpected in critically ill patients. Others have been found to have collapsing glomerulopathy, thrombotic microangiopathy and diverse underlying kidney diseases. A primary kidney pathology related to COVID-19 has not yet emerged. Thus far direct infection of the kidney, or its impact on clinical disease remains controversial. The management of AKI is currently supportive.Case PresentationThe patient presented here was positive for SARS-CoV-2, had severe acute respiratory distress syndrome and multi-organ failure. Within days of admission to the intensive care unit he developed oliguric acute kidney failure requiring dialysis. Acute kidney injury developed in the setting of hemodynamic instability, sepsis and a maculopapular rash. Over the ensuing days the patient also developed transfusion-requiring severe hemolysis which was Coombs negative. Schistocytes were present on the peripheral smear. Given the broad differential diagnoses for acute kidney injury, a kidney biopsy was performed and revealed granulomatous tubulo-interstitial nephritis with some acute tubular injury. Based on the biopsy findings, a decision was taken to adjust medications and initiate corticosteroids for presumed medication-induced interstitial nephritis, hemolysis and maculo-papular rash. The kidney function and hemolysis improved over the subsequent days and the patient was discharged to a rehabilitation facility, no-longer required dialysis.ConclusionsAcute kidney injury in patients with severe COVID-19 may have multiple causes. We present the first case of granulomatous interstitial nephritis in a patient with COVID-19. Drug-reactions may be more frequent than currently recognized in COVID-19 and are potentially reversible. The kidney biopsy findings in this case led to a change in therapy, which was associated with subsequent patient improvement. Kidney biopsy may therefore have significant value in pulling together a clinical diagnosis, and may impact outcome if a treatable cause is identified.

Granulomatous Interstitial Nephritis - A Series of Six Cases.

Granulomatous interstitial nephritis is an uncommon variant accounting for about 6% of all tubulointerstitial nephritis. The etiology can be drugs such as antibiotics and nonsteroidal anti-inflammatory drugs and infections such as tuberculosis, sarcoidosis, and fungal infections. Renal biopsy remains the gold standard for establishing the diagnosis. Here, we present a series of six cases of granulomatous interstitial nephritis, of which two cases were associated with lupus nephritis and another two cases with crescentic glomerulonephritis. Focal segmental glomerulosclerosis and mesangiosclerosis with chronic tubulointerstitial nephritis were detected in the rest of the cases. Most of the patients presented with features of nephrotic syndrome. Urine analysis showed albuminuria in all cases. In renal biopsy, interstitial epithelioid cell granuloma was a constant feature along with which there were foci of necrosis and moderate fibrosis in few cases. But none of our cases had any relevant history of prolonged drug intake. Tuberculosis and fungal infections were also ruled out. Thereby in this case series, we subgroup all the cases into two category four cases associated with granulomatous nephritis and two cases with idiopathic granulomatous nephritis.

318 A Case of Granulomatous Interstitial Nephritis in a Patient with Crohn's Disease

318 A Case of Granulomatous Interstitial Nephritis in a Patient with Crohn's Disease

Masks of urogenital tuberculosis as the cause of diagnostic errors

Urogenital tuberculosis does not have pathognomonic symptoms, so diagnostic errors are quite common. This systematic review of literature was conducted to identify the causes and estimate the incidence of erroneous diagnoses. We critically evaluated some articles in which the authors describe observations of urogenital tuberculosis as rare and unusual because they never encountered this disease, but in fact that were typical manifestations of genitourinary tuberculosis. The authors analyzed and illustrated the features of urinary tuberculosis in patients with pulmonary tuberculosis, differential diagnosis of urogenital tuberculosis and kidney cancer and male genitourinary organs, described errors in the diagnosis of urethral, testicular, penile, prostatic and epididymal tuberculosis. Urolithiasis was described as a mask and concomitant disease of urogenital tuberculosis. Really rare forms of bladder tuberculosis as the cause of diagnostic errors are described. Examples of fatal outcomes of urogenital tuberculosis are given. The authors analyzed cases of granulomatous interstitial nephritis due to tuberculosis infection and tuberculosis of the renal artery as the cause of renovascular hypertension. The most common causes of late diagnosis of urogenital tuberculosis are the absence of a typical pattern and the tendency to manifest under the guise of other diseases.

Acute interstitial nephritis after sequential ipilumumab - nivolumab therapy of metastatic melanoma

BackgroundThe anti-Programmed Death receptor 1 (anti-PD-1) antibodies nivolumab and pembrolizumab are new treatments in metastatic melanoma. Immunotherapies are best known to be responsible for thrombotic microangiopathy. However, immune interstitial nephritis has been described in a patient treated by nivolumab and ipilimumab concomitantly, and three cases of granulomatous interstitial nephritis have been reported with ipilimumab monotherapy. We report herein a case of acute interstitial immune nephritis in a patient treated with nivolumab after ipilimumab for pulmonary metastatic melanoma.Case presentationInterstitial nephritis was diagnosed after acute kidney injury following three cycles and was confirmed by kidney biopsy. Kidney injury responded rapidly to prednisolone, which was then gradually reduced. As a follow-up computed tomography scan indicated mixed response, with minimal size progression of a pulmonary nodule, but a significant reduction in the size of the other nodules, nivolumab was reintroduced after renal function improvement. Low-dose corticosteroids were first maintained during nivolumab treatment and subsequently discontinued. Only one month after prednisolone discontinuation, creatinine levels increased. A second kidney biopsy confirmed relapse of acute interstitial nephritis.ConclusionsTo our knowledge, this is the first case of nivolumab-induced acute interstitial immune nephritis. This case highlights that anti-PD-1 immunotherapy may be continued when renal function is adequate, and this requires close interaction between dermatologists and nephrologists. This adverse effect should be made known to prescribers as nivolumab is associated with significant improvement of survival in metastatic melanoma and may be used in many different types of cancer.

Granulomatous interstitial nephritis in native and allograft renal biopsies: experience of 16 cases from a tertiary care hospital

Introduction Granulomatous interstitial nephritis (GIN) is an uncommon histological diagnosis and is seen in Materials and methods A retrospective study was done between January 2009 and November 2013. On reviewing biopsy records of 1484 native and graft renal biopsies, 16 cases of granulomatous interstitial nephritis were identified. Histopathology slides were reviewed and clinical along with biochemical/immunological data was analysed along with patient outcome. Results GIN was diagnosed in 14 native biopsies, two allograft renal biopsies accounting for 1.08% of total renal biopsies. There were 10 males and 6 females. Mean age of the patients was 34 years. Majority of the patients had advanced renal failure with mean serum creatinine of 6.25 mg/dL at presentation. Serum calcium levels were normal in all patients and ANA was negative. Tuberculosis was the most common aetiology (9/16), other being drugs, infections, etc. Only two patients progressed to ESRD. Mild interstitial fibrosis/tubular atrophy were seen in 88% cases. Conclusion Granulomatous interstitial nephritis is a rare condition in both native renal and graft biopsies. Tuberculosis is the most common aetiology in India as opposed to drugs in west. The factors associated with adverse clinical outcome were higher creatinine at presentation and increased severity of interstitial fibrosis and tubular atrophy.

Granulomatous interstitial nephritis in chronic lymphocytic leukaemia

We present a case of granulomatous interstitial nephritis (GIN) associated with chronic lymphocytic leukaemia (CLL). GIN is a rare pathological finding noted in renal biopsy specimens. Furthermore, CLL does not usually cause GIN. In this case, acute renal injury probably resulted from GIN, and urgent dialysis was required, despite sufficient chemotherapy. Immunohistochemical analyses of a biopsy specimen revealed invasion of CD20( +) CLL cells, surrounded by reactive T cells, and granuloma formation. Thus, CLL may induce secondary interstitial nephritis as a granulomatous reaction.

209: Granulomatous Interstitial Nephritis Secondary to Carbamazepine Causing Acute Renal Failure

GRANULOMATOUS INTERSTITIAL NEPHRITIS SECONDARY TO CARBAMAZEPINE CAUSING ACUTE RENAL FAILURE Prashanth Podaralla, Nagaraju Sarabu, Marcos Rothstein, 1 Barnes Jewish Hospital, Washington University, St. Louis, MO. 2 St. Luke’s Hospital, Chesterfield, MO. Granulomatous interstitial nephritis (GIN) is a specific subtype of interstitial nephritis that is present in 0.5% to 0.9% of native kidney biopsies. Thus, GIN is a rare histologic finding and has been associated with medications, infections, sarcoidosis and Wegener’s granulomatosis. Common medications causing GIN include antibiotics, non-steroidal antiinflammatory drugs, allopurinol, diuretics and anticonvulsants. We present the case of a 77-year-old male with past medical history of hypertension, hypothyroidism and seizure disorder, who came with one week history of nausea, vomiting and decreased urine output. About two months prior to presentation, he was started on carbamazepine for his seizures. Physical examination was remarkable only for bilateral basilar crackles. Laboratory data showed normal white cell count with slightly increased eosinophil count, normal hemoglobin, blood urea nitrogen 132 mg/dl, and creatinine 9.4 mg/dl (baseline 1.1, 3 weeks ago). Urine analysis showed 3+ protein and spot urine protein to creatinine ratio was 2.43. He required dialysis soon after presentation. Percutaneous biopsy of the kidney showed extensive interstitial non-caseating granulomatous inflammation with eosinophils. Patient also developed a maculopapular rash all over his trunk during hospital stay. CT scan of the chest failed to show any hilar lymphadenopathy or pulmonary infiltrates. Based on the clinical presentation, temporal association with carbamazepine, and biopsy findings, the diagnosis of carbamazepine induced GIN was made. Carbamazepine was stopped and he was switched to Zonisamide for seizure control. Patient was started on prednisone, which dramatically reversed his acute renal failure, and he came off of dialysis within 4 weeks. After one year of presentation he retains his normal kidney function. In conclusion, we present a case of GIN due to carbamazepine requiring renal replacement therapy, which is rare, but a recognized severe complication of carbamazepine.

Clarithromycin-induced granulomatous tubulointerstitial nephritis

Acute interstitial nephritis is an important cause of acute renal dysfunction, accounting for up to 15% of patients hospitalized for acute renal dysfunction. Drug-induced interstitial nephritis represents 4% of all cases studied histologically, with an estimated frequency of 8% [1]. We present a case of granulomatous interstitial nephritis in a 38-year-old woman prescribed clarithromycin for pharyngitis. A 38-year-old woman was admitted with a history of abnormal renal function. She was seen by her GP with a history of sore throat and nasal discharge for which she was started on a course of clarithromycin. Whilst on these medications, she developed fever, night sweats, headache, rash and mouth ulcers. A subsequent blood test, done because of her worsening symptoms, revealed deranged renal function, following which she was referred to the hospital. Her past medical history included reactive arthritis requiring a short period of methotrexate more than 2 years previously but this was currently quiescent. She denied any drug allergy but was on clarithromycin and homeopathic medication (transfer factor: an immuno-modulating drug). On examination she was apyrexial, tachycardic (pulse103 bpm) and had a blood pressure of 152/92. General and systemic examination was unremarkable. Investigations revealed: urine analysis pH-5.0, leucocytes<10/mm, and few squamous cells; no blood or protein was detected; haemoglobin 10.2 g/dl, white cell count 9.2 10/l (Neu-8.47, Eos-nil), platelets 513 10/l, erythrocyte Sedimentation Rate (ESR) 136; sodium 137mmol/l, potassium 4.4mmol/l, bicarbonate 20mmol/l, urea 17.3mmol/l, creatinine 654mmol/l, calcium 2.56mmol/l, phosphate 1.38mmol/l, albumin 30 g/l and C-reactive protein (CRP) 84. Autoantibody screen, Anti-glomerular basement membrane (GBM) and anti-neutrophilic Cytoplasmic Antibody (ANCA) were negative. Ultrasound of kidneys was normal. Subsequent renal biopsy showed diffuse inflammatory cell infiltrate within the interstitium, comprising of lymphocytes, plasma cells and numerous eosinophils with non-caseating epitheloid granuloma. A diagnosis of Tubulinointerstitial Nephritis (TIN) was made, all medication was stopped and the patient was started on a short course of oral steroids, following which she made a complete recovery. Drug-induced acute tubulointerstitial nephritis is an inflammatory process involving the tubules, the space between the tubules and the glomeruli. It is mediated by T-cell hypersensitivity reaction and cytotoxic T-cell injury. Renal biopsy is the gold standard for diagnosis. Stopping the suspected medication forms the main component of treatment, with most patients recovering rapidly on withdrawal of the offending drug. Corticosteriod and immunosuppresants, in cases where there is no significant improvement in the renal function, may be of value. Recovery is more rapid in those individuals who have been exposed to the drug for <2 weeks, in comparison to those who have taken the suspected medication for more than 3 weeks. Epithelioid and non-caseating giant-cell granulomas are found in some cases, especially those in which acute interstitial nephritis is secondary to drugs [2]. Granulomatous TIN has been described with drugs like fluoroquinolines and lamotrigine [3,4]. There has been one report of granulomatous reaction in a patient on a combination of dihydrocodeine, amoxicillin, erythromycin and phenylpropanalamine [5]. Other reported cases of granulomatous TIN are seen in infections (tuberculosis), Wegener’s granulomatosis and in sarcoidosis. Idiopathic granulomatous TIN in the absence of features of extra-renal sarcoid has also been described, but these patients may have associated features of hypercalcaemia and raised serum angiotensin converting enzyme [6,7], which were absent in our patient. In our case, the patient was on both clarithromycin and homeopathic medication, which was discontinued immediately after the initial diagnosis was made. Correspondence and offprint requests to: Dr V. K. Audimoolam, 72, Scotney Garden, St Peter Street, Maidstone, Kent, ME16 0GR, UK. Email: vindok@hotmail.com Nephrol Dial Transplant (2006) 21: 2654–2655

A Case of Granulomatous Interstitial Nephritis with Progressive Renal Impairment Due to Sarcoidosis in the Course of Spontaneous Improvement of Pulmonary Lesions

A Case of Granulomatous Interstitial Nephritis with Progressive Renal Impairment Due to Sarcoidosis in the Course of Spontaneous Improvement of Pulmonary Lesions

Néphropathie interstitielle granulomateuse au cours de la maladie de Whipple

We describe a case of granulomatous interstitial nephritis with fibrosis and with IgM and IgA deposits in a Whipple's disease. The renal insufficiency did not change after ten months of treatment by Doxyclin.

A case of granulomatous interstitial nephritis presented reversible renal failure treated with the steroid therapy

A case of granulomatous interstitial nephritis presented reversible renal failure treated with the steroid therapy

RENAL DISEASE AND SARCOIDOSIS

Renal involvement in sarcoidosis has recently been emphasized with increasing reports of associated glomerulonephritis. We report in detail a further case of mesangiocapillary glomerulonephritis in association with sarcoidosis. In addition, a review of 75 cases of sarcoidosis at Royal Melbourne Hospital over a 10-year period revealed one case of membranous glomerulonephritis and one case of granulomatous interstitial nephritis. Seven patients in the series had nephrocalcinosis, and eight further patients had abnormalities of urinary sediment of clinical symptoms of renal involvement. These findings suggest that, though renal failure is rare, renal involvement in sarcoidosis is more frequent than has previously been reported.