A 56-year-old woman diagnosed with pSS 13 years earlier.
He had dry syndrome, asthenia and frequent episodes of polyarthritis.
During this time, she continued on prolonged treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids.
In addition, in recent months, methotrexate had been associated with poor symptom improvement.
Three months after starting dental treatment with dental implants, the patient was admitted with facial edema, fever and decreased diuresis.
Physical examination revealed general deterioration, blood pressure (BP) of 160/90 mmHg, fever and submandibular edema with evidence of active infection in the lower dental arch.
There were no distal edemas or skin lesions.
In the analytical study Hb 9.2 g/dl, creatinine 2.9 mg/dl, urea 110 mg/dl, liver profile, lipids, ANCA and normal immunoglobulins were detected.
ANA were positive, anti-DNA negative.
C3 and C4 were low, 46 and 1.6 mg/dl, respectively.
Serology for HBV, HCV and HIV negative.
Blood cultures were negative.
ANA, anti-Ro, anti-LA and rheumatoid factor (RF) antibodies remained positive since the diagnosis of pSS.
He had also occasionally presented hypocomplementemia.
Proteinuria (2 g/l) and microhematuria were observed in urine.
Renal ultrasound was normal.
She developed persistent fever despite antibiotic therapy and oliguria, requiring dialysis.
Acute glomerulonephritis (GN), probably postinfectious, given the history of mandibular infectious process and hypocomplementemia, renal biopsy was performed with the following results:
The optical microscopy cylinder contained 8 glomeruli with diffuse capillary occlusion by proteinaceous material thrombi PAS positive.
In some glomeruli they were accompanied by segmentary inflammatory cells.
The interstitium showed isolated foci of lymphoplasmacytic inflammation and the arteries showed no alterations.
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In the direct immunofluorescence study (DIF) an intense positivity was observed in the thrombi of IgG, IgM, kappa and lambda, being weaker for C3 and IgA.
C1q and fibrinogen were negative.
The ultrastructural study was carried out later.
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Anatomopathological diagnosis
Glomerulopathies with massive intracapillary thrombi of immunoglobulins suspecting cryoglobulinemic glomerulopathy associated with SS.
