A 77-year-old woman was referred to the nephrology service due to plasma creatinine of 2.4 mg/dl. Among her personal history there were several surgical interventions (meniscus in 1985; thymoma diagnosed with sclerotic variceal acid fracture in July 20, 2008); primary choledocholic acid in July 2008;
Biliary catheterization with sphincterectomy and dilatation of stenosis areas had been performed on several occasions.
She had also been diagnosed with inflammatory bowel disease at the same time. Subsequent follow-up showed normal colons, sometimes showing minimal ulcerations at the iliocecal level and sometimes with minimal ulceration at the intestinal level.
Periodontitis of unknown etiology in January 2010.
Gotrosis bilateral.
Oral iron intolerance.
He had no toxic habits.
At the first time she was seen in the outpatient clinic she was under treatment with zolpidem, 10 mg/day; ursodeoxycholic acid, 1250 mg/day; pantoprazole, 40 mg/day;
In the interview, she reported intense tiredness, dyspnea on medium efforts; decreased appetite; occasional nausea with cough; habitual constipation of about 48 hours that alternated with diarrhea of 3 to 4 stools a day; no episodes of hematuria or urine output a day.
As for their family history, deceased parents in old age and three brothers died from tumors.
Physical examination: height 159 cm; weight 53 kg. Blood pressure 137/72 mmHg; heart rate 95 bpm.
He did not have jugular engorgement; carotid arteries stenosis and symmetrical; normal cardiopulmonary resuscitation; in the abdomen, he showed hepatomegaly around the abdomen, four non-painful auscultations of the right lobe,
Extremities: no edema and distal pulses were present.
After reviewing the analytical history, it was observed that in November 2010 plasma creatinine ranged from 2.4-2.5 mg/dl; in December 2010, plasma creatinine was 2.9 mg/dl and in January 2011, 2.7 mg/dl.
Additional tests in January and February 2011 include: cholesterol: 204 mg/dl; GOT (glutamate-oxalacetate-female-transaminase): 37 U/l; GPTH-glutarate:
The rest of the normal biochemistry was normal.
Hematocrit: 35.1%; hemoglobin: 11.3 g/dl; normal rest.
Coagulation study: activated partial thromboplastin time: 45 seconds.
IgM anticardiolipin positive: 21.80 U MPL/ml (normal: 0.5-11).
In the 24-hour urine analysis: proteinuria: 0.53 g/24 hours; creatinine clearance: 17 ml/min. The systematic urine analysis was negative.
Immunological study showed positivity for antineutrophil cytoplasmic antibodies (ANCA) (anti-MPO and anti-PR3 negative); antinuclear antibodies (ANA), anti-DNA, anti smooth muscle antibodies were negative.
A decrease in immunoglobulins was detected: IgG: 253 mg/dl (normal: 751-1560); IgM: 10 mg/dl (normal: 46-304); IgA 81 mg/dl (normal: 82-453).
Complement, rheumatoid factor, C-reactive protein and ceruloplasmin were within normal range.
Serology of hepatitis B and C virus, as well as human immunodeficiency virus, was negative.
Thyroid hormones and antithyroid antibodies were normal.
The intact parathyroid hormone was 149 pg/ml.
Blood electrophoresis showed a decrease in immunoglobulins, while urine showed non-selective proteinuria.
Bence-Jones proteinuria was negative.
In imaging tests (renal ultrasound): kidneys with normal size, morphology and echogenicity, without stones or dilatation.
Percutaneous renal biopsy was performed with the following findings: 4 glomeruli, 2 of them completely sclerotic.
Immunofluorescence was negative for IgG, IgA, IgM and C3.
At the interstitium, a dense lymphocytic infiltrate was observed, which expanded and occupied the entire tissue, assuming the usual architecture of the renal parenchyma.
The presence of fibrosis due to the existing infiltrate was not well evaluated.
Figure 2A shows the immunohistochemistry with CD3 (monoclonal antibody that marks T lymphocytes in general) and shows that the majority of the infiltrate is immunohistochemical with CD T lymphocytes, and Figure 2B.
The final pathological diagnosis was severe tubulointerstitial nephropathy (interstitial infiltrate with CD4 positive T lymphocyte predominance).
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With the biopsy findings, treatment with prednisone, 50 mg/day, in descending order was indicated.
Eight months later, the patient maintained renal function (plasma creatinine 2.2 mg/dl, clearance 20 ml/min and proteinuria 0.49 g/24 h).
Hepatic function: AST: 24 U/l; ALT: 18 U/l; GGT: 172 U/l; alkaline phosphatase: 342 U/l.
