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Transaminases&#44; LDH&#44; CK&#44; cholesterol&#44; triglycerides&#44; HDL&#44; and LDL&#44; were normal&#46; Urinary sediment had &#62;100 red blood cells per field &#40;90&#37; dysmorphic&#41;&#44; with a 24<span class="elsevierStyleHsp" style=""></span>h proteinuria of 1&#46;3<span class="elsevierStyleHsp" style=""></span>g&#46; Serology was negative for HIV&#44; hepatitis B and C virus&#46; ANA&#44; ANCA&#44; and anti-glomerular basement membrane antibodies were negative&#44; and C3 and C4 were normal&#46; Chest X-ray showed vascular redistribution and a left-sided pleural effusion&#46; Abdominal ultrasound showed kidneys of normal size with increased cortical echogenicity with no other abnormalities&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Percutaneous renal biopsy was performed and showed a proliferative endocapillary and extracapillary glomerulonephritis affecting most glomeruli &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Immunofluorescence was negative&#44; there were no amyloid deposits&#44; and no acid-alcohol fast bacilli using Fite technique&#46; Treatment was started with 3 boluses of 6-methyl-prednisolone and thereafter oral prednisone &#40;60<span class="elsevierStyleHsp" style=""></span>mg daily&#41; and cyclophosphamide &#40;100<span class="elsevierStyleHsp" style=""></span>mg daily&#41;&#46; Renal function progressively deteriorated&#44; and treatment with haemodialysis was started via a tunnelled right jugular catheter&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In May 2011&#44; pancytopenia was observed&#44; so cyclophosphamide was stopped and treatment with sodium mycophenolate was started &#40;360<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; In June 2011&#44; he was readmitted with bilobar pneumonia&#44; so sodium mycophenolate treatment was stopped definitively&#44; and prednisone continued&#44; at a reducing dose&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In August 2011&#44; due to the appearance of cutaneous lesions in the lower limbs&#44; biopsy was performed&#44; which showed areas of dermal necrosis associated with macrophages with focal images of leukocytoclastic vasculitis of small vessels&#44; compatible with a diagnosis of type II lepra reaction &#40;borderline lepromatous&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Treatment was started with dapsone &#40;100<span class="elsevierStyleHsp" style=""></span>mg daily&#41;&#44; clofazimine &#40;50<span class="elsevierStyleHsp" style=""></span>mg daily&#41;&#44; and rifampicin &#40;300<span class="elsevierStyleHsp" style=""></span>mg per month&#41;&#46; He was readmitted in October 2011 for severe anaemia with a haemoglobin of 5&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; and diagnosed with haemolytic anaemia secondary to dapsone&#44; which was stopped&#46; The patient continued on haemodialysis treatment&#44; and died following a haemopericardium in relation to the change of jugular catheter in July 2012&#46; Post-mortem examination was not possible&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Conclusions&#58; leprosy&#44; particularly in the lepromatous form&#44; can cause secondary renal amyloidosis&#44; especially in patients who have recurrent episodes of associated erythema nodosum or chronic skin ulcers&#59; tubulointerstitial nephropathies&#44; both acute and chronic can also occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a> Finally&#44; several types of immune complex glomerulonephritis have been described&#44; such as proliferative endocapillary&#44; proliferative mesangial&#44; membranoproliferative&#44; and focal glomerulosclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Extracapillary forms have been described in exceptional cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#8211;10</span></a> Typically&#44; patients present with acute renal failure&#46; In some cases&#44; the presence of bacilli has been demonstrated in the renal parenchyma at a glomerular level and in the interstitium&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The mechanisms connecting extracapillary glomerulonephritis with negative immunofluorescence and leprosy are not well-known&#44; but it is possible that the immune abnormalities produced in leprosy could favour the generation of glomerulonephritis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In these patients&#44; the appropriate treatment must be considered&#46; In our case&#44; treatment was started with cyclophosphamide&#44; and subsequently&#44; mycophenolate sodium with steroids&#46; It is highly possible that this treatment contributed was key in the reactivation of leprosy as was confirmed on cutaneous biopsy&#44; therefore prophylactic treatment with dapsone or clofazimine should be considered in such cases&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Leprosy treatment in patients on dialysis is difficult because there is little experience with the drugs used&#44; and the dose must be adjusted&#46; The risk of side effects increases&#44; and in fact&#44; our patient had severe haemolytic anaemia&#44; possibly secondary to dapsone treatment&#46;</p></span>"
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Letters to the Editor - Brief Case Reports
Extracapillary glomerulonephritis and leprosy: An uncommon association
Glomerulonefritis extracapilar y lepra: una asociación infrecuente
Gabriel de Arribaa,b,
Corresponding author
garribad@sescam.jccm.es

Corresponding author.
, Ruth A. Filallosa, Alberto de Lorenzoa, José Ramón Rodríguez-Palomaresa,b, Cristian Pernab,c
a Nefrología, Hospital Universitario de Guadalajara, Guadalajara, Spain
b Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá (UAH), Guadalajara, Spain
c Anatomía Patológica, Hospital Universitario de Guadalajara, Guadalajara, Spain
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with both neurological and cutaneous involvement&#46; He was admitted in March 2011 with oedema&#44; haematuria&#44; and worsening of renal function&#46; On examination&#44; he was noted to have leonine facies&#44; loss of eyebrows&#44; and a saddle nose&#46; His skin was rough with xerostomia and thickening&#44; and there were erythematous macules on the limbs&#46; BP was 168&#47;104&#46; Venous pressure was elevated&#44; and there were bibasal crepitations and peripheral oedema&#46; There was reduced sensibility to touching and pain in the limbs&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Blood test revealed a haemoglobin of 11&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; leukocytes 6660&#47;mm<span class="elsevierStyleSup">3</span>&#44; platelets 173&#44;000<span class="elsevierStyleMonospace">&#47;</span>mm<span class="elsevierStyleSup">3</span>&#44; creatinine 2&#46;31<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; and urea 93<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Transaminases&#44; LDH&#44; CK&#44; cholesterol&#44; triglycerides&#44; HDL&#44; and LDL&#44; were normal&#46; Urinary sediment had &#62;100 red blood cells per field &#40;90&#37; dysmorphic&#41;&#44; with a 24<span class="elsevierStyleHsp" style=""></span>h proteinuria of 1&#46;3<span class="elsevierStyleHsp" style=""></span>g&#46; Serology was negative for HIV&#44; hepatitis B and C virus&#46; ANA&#44; ANCA&#44; and anti-glomerular basement membrane antibodies were negative&#44; and C3 and C4 were normal&#46; Chest X-ray showed vascular redistribution and a left-sided pleural effusion&#46; Abdominal ultrasound showed kidneys of normal size with increased cortical echogenicity with no other abnormalities&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Percutaneous renal biopsy was performed and showed a proliferative endocapillary and extracapillary glomerulonephritis affecting most glomeruli &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Immunofluorescence was negative&#44; there were no amyloid deposits&#44; and no acid-alcohol fast bacilli using Fite technique&#46; Treatment was started with 3 boluses of 6-methyl-prednisolone and thereafter oral prednisone &#40;60<span class="elsevierStyleHsp" style=""></span>mg daily&#41; and cyclophosphamide &#40;100<span class="elsevierStyleHsp" style=""></span>mg daily&#41;&#46; Renal function progressively deteriorated&#44; and treatment with haemodialysis was started via a tunnelled right jugular catheter&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In May 2011&#44; pancytopenia was observed&#44; so cyclophosphamide was stopped and treatment with sodium mycophenolate was started &#40;360<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; In June 2011&#44; he was readmitted with bilobar pneumonia&#44; so sodium mycophenolate treatment was stopped definitively&#44; and prednisone continued&#44; at a reducing dose&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In August 2011&#44; due to the appearance of cutaneous lesions in the lower limbs&#44; biopsy was performed&#44; which showed areas of dermal necrosis associated with macrophages with focal images of leukocytoclastic vasculitis of small vessels&#44; compatible with a diagnosis of type II lepra reaction &#40;borderline lepromatous&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Treatment was started with dapsone &#40;100<span class="elsevierStyleHsp" style=""></span>mg daily&#41;&#44; clofazimine &#40;50<span class="elsevierStyleHsp" style=""></span>mg daily&#41;&#44; and rifampicin &#40;300<span class="elsevierStyleHsp" style=""></span>mg per month&#41;&#46; He was readmitted in October 2011 for severe anaemia with a haemoglobin of 5&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; and diagnosed with haemolytic anaemia secondary to dapsone&#44; which was stopped&#46; The patient continued on haemodialysis treatment&#44; and died following a haemopericardium in relation to the change of jugular catheter in July 2012&#46; Post-mortem examination was not possible&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Conclusions&#58; leprosy&#44; particularly in the lepromatous form&#44; can cause secondary renal amyloidosis&#44; especially in patients who have recurrent episodes of associated erythema nodosum or chronic skin ulcers&#59; tubulointerstitial nephropathies&#44; both acute and chronic can also occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a> Finally&#44; several types of immune complex glomerulonephritis have been described&#44; such as proliferative endocapillary&#44; proliferative mesangial&#44; membranoproliferative&#44; and focal glomerulosclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Extracapillary forms have been described in exceptional cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#8211;10</span></a> Typically&#44; patients present with acute renal failure&#46; In some cases&#44; the presence of bacilli has been demonstrated in the renal parenchyma at a glomerular level and in the interstitium&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The mechanisms connecting extracapillary glomerulonephritis with negative immunofluorescence and leprosy are not well-known&#44; but it is possible that the immune abnormalities produced in leprosy could favour the generation of glomerulonephritis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In these patients&#44; the appropriate treatment must be considered&#46; In our case&#44; treatment was started with cyclophosphamide&#44; and subsequently&#44; mycophenolate sodium with steroids&#46; It is highly possible that this treatment contributed was key in the reactivation of leprosy as was confirmed on cutaneous biopsy&#44; therefore prophylactic treatment with dapsone or clofazimine should be considered in such cases&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Leprosy treatment in patients on dialysis is difficult because there is little experience with the drugs used&#44; and the dose must be adjusted&#46; The risk of side effects increases&#44; and in fact&#44; our patient had severe haemolytic anaemia&#44; possibly secondary to dapsone treatment&#46;</p></span>"
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