Images in Pratice
Kidney Research
Kidney Res Clin Pract 36:296-297, 2017(3) pISSN: 2211-9132 • eISSN: 2211-9140 https://doi.org/10.23876/j.krcp.2017.36.3.296
and
Clinical Practice
Staphylococcal infection-associated crescentic immunoglobulin A nephropathy Jong Hwan Jung, Ju Hung Song, Seon-Ho Ahn Division of Nephrology, Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
A 49-year-old man without a history of chronic disease presented to our hospital with acute fever, dyspnea, and oliguria. His vital signs were: blood pressure 100/60 mmHg, heart rate 120 beats per minute, and body temperature 38.5°C. Laboratory findings were: serum creatinine 2.99 mg/dL, leukocytes 21,230 × 103/μL, hemoglobin 7.6 g/dL, platelets 60,000/μL, and C-reactive protein 183.46 mg/L. Additionally, perinuclear anti-neutrophil cytoplasmic antibody (ANCA) and cytoplasmic ANCA were elevated, and C3 was decreased. However, there were no indications of vasculitis. Computed tomography
revealed multifocal pneumonic infiltration along with bilateral cavitary lung lesions and a perirenal hematoma. We initiated empirical antibiotics. Blood cultures revealed methicillin-resistant Staphylococcus aureus , and the patient exhibited signs of uremia, for which he underwent emergency hemodialysis. Echocardiography revealed a tricuspid valve vegetation measuring 2.0 × 0.79 cm. While his renal function and pneumonic infiltration improved after 4 weeks, proteinuria persisted. A renal biopsy showed endocapillary proliferation and increased mesangial immunoglobulin A (IgA) accumulation ac-
A
B
Figure 1. Renal biopsy findings. (A) High-power view showing a fibrocellular crescent (arrow) and endocapillary proliferation combined with mesangial hypercelluarity (hematoxylyn-eosin stain, ×400). (B) Representative image of immunofluorescence showing mesangial infiltration and staining of immunoglobulin A complexes.
Received June 27, 2017; Revised July 6, 2017; Accepted July 17, 2017 Correspondence: Seon-Ho Ahn Department of Internal Medicine, Wonkwang University Hospital 895 Muwang-ro, Iksan 54538, Korea. E-mail: [email protected] Copyright © 2017 by The Korean Society of Nephrology This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC
Jung, et al. Staphylococcus -associated crescentic IgA nephropathy
companied by fibrocellular crescents (Fig. 1)-findings typically observed in crescentic IgA nephropathy. We initiated steroid therapy after ensuring complete remission of Staphylococcus infection. The patient’s renal condition stabilized following steroid administration. Infectious endocarditis often results in proliferative or crescentic glomerulonephritis (GN), primarily presenting as acute kidney injury. Additionally, the histological pattern of Staphylococcus infection-associated GN resembles IgA nephropathy more than other post-infection GN. Thus, Staphylococcus -associated GN mimicking crescentic IgA nephropathy should be considered in the differential diagnosis of cases showing sudden development of azotemia and significant proteinuria in patients diagnosed with staphylococcal endocarditis. However,
while steroids form the mainstay of treatment for crescentic IgA nephropathy, Staphylococcus -associated GN is primarily treated with antibiotics. Steroid therapy could be administered following complete remission of infection in patients who demonstrate fibrocellular crescents and severe proteinuria.
Conflicts of interest All authors have no conflicts of interest to declare.
Acknowledgments This work was supported by Wonkwang University in 2017.
www.krcp-ksn.org
297
Kidney Research
Kidney Res Clin Pract 36:296-297, 2017(3) pISSN: 2211-9132 • eISSN: 2211-9140 https://doi.org/10.23876/j.krcp.2017.36.3.296
and
Clinical Practice
Staphylococcal infection-associated crescentic immunoglobulin A nephropathy Jong Hwan Jung, Ju Hung Song, Seon-Ho Ahn Division of Nephrology, Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
A 49-year-old man without a history of chronic disease presented to our hospital with acute fever, dyspnea, and oliguria. His vital signs were: blood pressure 100/60 mmHg, heart rate 120 beats per minute, and body temperature 38.5°C. Laboratory findings were: serum creatinine 2.99 mg/dL, leukocytes 21,230 × 103/μL, hemoglobin 7.6 g/dL, platelets 60,000/μL, and C-reactive protein 183.46 mg/L. Additionally, perinuclear anti-neutrophil cytoplasmic antibody (ANCA) and cytoplasmic ANCA were elevated, and C3 was decreased. However, there were no indications of vasculitis. Computed tomography
revealed multifocal pneumonic infiltration along with bilateral cavitary lung lesions and a perirenal hematoma. We initiated empirical antibiotics. Blood cultures revealed methicillin-resistant Staphylococcus aureus , and the patient exhibited signs of uremia, for which he underwent emergency hemodialysis. Echocardiography revealed a tricuspid valve vegetation measuring 2.0 × 0.79 cm. While his renal function and pneumonic infiltration improved after 4 weeks, proteinuria persisted. A renal biopsy showed endocapillary proliferation and increased mesangial immunoglobulin A (IgA) accumulation ac-
A
B
Figure 1. Renal biopsy findings. (A) High-power view showing a fibrocellular crescent (arrow) and endocapillary proliferation combined with mesangial hypercelluarity (hematoxylyn-eosin stain, ×400). (B) Representative image of immunofluorescence showing mesangial infiltration and staining of immunoglobulin A complexes.
Received June 27, 2017; Revised July 6, 2017; Accepted July 17, 2017 Correspondence: Seon-Ho Ahn Department of Internal Medicine, Wonkwang University Hospital 895 Muwang-ro, Iksan 54538, Korea. E-mail: [email protected] Copyright © 2017 by The Korean Society of Nephrology This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC
Jung, et al. Staphylococcus -associated crescentic IgA nephropathy
companied by fibrocellular crescents (Fig. 1)-findings typically observed in crescentic IgA nephropathy. We initiated steroid therapy after ensuring complete remission of Staphylococcus infection. The patient’s renal condition stabilized following steroid administration. Infectious endocarditis often results in proliferative or crescentic glomerulonephritis (GN), primarily presenting as acute kidney injury. Additionally, the histological pattern of Staphylococcus infection-associated GN resembles IgA nephropathy more than other post-infection GN. Thus, Staphylococcus -associated GN mimicking crescentic IgA nephropathy should be considered in the differential diagnosis of cases showing sudden development of azotemia and significant proteinuria in patients diagnosed with staphylococcal endocarditis. However,
while steroids form the mainstay of treatment for crescentic IgA nephropathy, Staphylococcus -associated GN is primarily treated with antibiotics. Steroid therapy could be administered following complete remission of infection in patients who demonstrate fibrocellular crescents and severe proteinuria.
Conflicts of interest All authors have no conflicts of interest to declare.
Acknowledgments This work was supported by Wonkwang University in 2017.
www.krcp-ksn.org
297
