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Filallos, Alberto de Lorenzo, José Ramón Rodríguez-Palomares, Cristian Perna" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Gabriel" "apellidos" => "de Arriba" "email" => array:1 [ 0 => "garribad@sescam.jccm.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ruth A." "apellidos" => "Filallos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Alberto" "apellidos" => "de Lorenzo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "José Ramón" "apellidos" => "Rodríguez-Palomares" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Cristian" "apellidos" => "Perna" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Nefrología, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá (UAH), Guadalajara, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Anatomía Patológica, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Glomerulonefritis extracapilar y lepra: una asociación infrecuente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 734 "Ancho" => 975 "Tamanyo" => 394368 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy. Methenamine-silver staining. Glomeruli are seen with increased cellularity, at an endocapillary level and with formation of extracapillary crescents.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Leprosy is a chronic disease caused by the intracellular bacillus <span class="elsevierStyleItalic">Mycobacterium leprae</span>, which primarily affects the skin and peripheral nerves.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The clinical picture is variable; there are paucibacillary forms with few lesions (tuberculoid leprosy), and multibacillary forms with numerous lesions (lepromatous leprosy), which occurs in patients with impaired cellular immunity.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The presence of extracapillary glomerulonephritis with leprosy is rare, and here we describe the case of a patient with both diseases.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This was a 79-year-old man diagnosed of leprosy at age 32, with both neurological and cutaneous involvement. He was admitted in March 2011 with oedema, haematuria, and worsening of renal function. On examination, he was noted to have leonine facies, loss of eyebrows, and a saddle nose. His skin was rough with xerostomia and thickening, and there were erythematous macules on the limbs. BP was 168/104. Venous pressure was elevated, and there were bibasal crepitations and peripheral oedema. There was reduced sensibility to touching and pain in the limbs.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Blood test revealed a haemoglobin of 11.9<span class="elsevierStyleHsp" style=""></span>g/dL, leukocytes 6660/mm<span class="elsevierStyleSup">3</span>, platelets 173,000<span class="elsevierStyleMonospace">/</span>mm<span class="elsevierStyleSup">3</span>, creatinine 2.31<span class="elsevierStyleHsp" style=""></span>mg/dL, and urea 93<span class="elsevierStyleHsp" style=""></span>mg/dL. Transaminases, LDH, CK, cholesterol, triglycerides, HDL, and LDL, were normal. Urinary sediment had >100 red blood cells per field (90% dysmorphic), with a 24<span class="elsevierStyleHsp" style=""></span>h proteinuria of 1.3<span class="elsevierStyleHsp" style=""></span>g. Serology was negative for HIV, hepatitis B and C virus. ANA, ANCA, and anti-glomerular basement membrane antibodies were negative, and C3 and C4 were normal. Chest X-ray showed vascular redistribution and a left-sided pleural effusion. Abdominal ultrasound showed kidneys of normal size with increased cortical echogenicity with no other abnormalities.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Percutaneous renal biopsy was performed and showed a proliferative endocapillary and extracapillary glomerulonephritis affecting most glomeruli (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Immunofluorescence was negative, there were no amyloid deposits, and no acid-alcohol fast bacilli using Fite technique. Treatment was started with 3 boluses of 6-methyl-prednisolone and thereafter oral prednisone (60<span class="elsevierStyleHsp" style=""></span>mg daily) and cyclophosphamide (100<span class="elsevierStyleHsp" style=""></span>mg daily). Renal function progressively deteriorated, and treatment with haemodialysis was started via a tunnelled right jugular catheter.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In May 2011, pancytopenia was observed, so cyclophosphamide was stopped and treatment with sodium mycophenolate was started (360<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h). In June 2011, he was readmitted with bilobar pneumonia, so sodium mycophenolate treatment was stopped definitively, and prednisone continued, at a reducing dose.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In August 2011, due to the appearance of cutaneous lesions in the lower limbs, biopsy was performed, which showed areas of dermal necrosis associated with macrophages with focal images of leukocytoclastic vasculitis of small vessels, compatible with a diagnosis of type II lepra reaction (borderline lepromatous) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Treatment was started with dapsone (100<span class="elsevierStyleHsp" style=""></span>mg daily), clofazimine (50<span class="elsevierStyleHsp" style=""></span>mg daily), and rifampicin (300<span class="elsevierStyleHsp" style=""></span>mg per month). He was readmitted in October 2011 for severe anaemia with a haemoglobin of 5.7<span class="elsevierStyleHsp" style=""></span>g/dL, and diagnosed with haemolytic anaemia secondary to dapsone, which was stopped. The patient continued on haemodialysis treatment, and died following a haemopericardium in relation to the change of jugular catheter in July 2012. Post-mortem examination was not possible.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Conclusions: leprosy, particularly in the lepromatous form, can cause secondary renal amyloidosis, especially in patients who have recurrent episodes of associated erythema nodosum or chronic skin ulcers; tubulointerstitial nephropathies, both acute and chronic can also occur.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–5</span></a> Finally, several types of immune complex glomerulonephritis have been described, such as proliferative endocapillary, proliferative mesangial, membranoproliferative, and focal glomerulosclerosis.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Extracapillary forms have been described in exceptional cases.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6–10</span></a> Typically, patients present with acute renal failure. In some cases, the presence of bacilli has been demonstrated in the renal parenchyma at a glomerular level and in the interstitium.<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, but it is possible that the immune abnormalities produced in leprosy could favour the generation of glomerulonephritis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In these patients, the appropriate treatment must be considered. In our case, treatment was started with cyclophosphamide, and subsequently, mycophenolate sodium with steroids. It is highly possible that this treatment contributed was key in the reactivation of leprosy as was confirmed on cutaneous biopsy, therefore prophylactic treatment with dapsone or clofazimine should be considered in such cases.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Leprosy treatment in patients on dialysis is difficult because there is little experience with the drugs used, and the dose must be adjusted. The risk of side effects increases, and in fact, our patient had severe haemolytic anaemia, possibly secondary to dapsone treatment.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de Arriba G, Fiallosa RA, de Lorenzoa A, Rodríguez-Palomaresa JR, Pernab C. Glomerulonefritis extracapilar y lepra: una asociación infrecuente. Nefrologia. 2016;36:313–314.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 734 "Ancho" => 975 "Tamanyo" => 394368 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy. Methenamine-silver staining. Glomeruli are seen with increased cellularity, at an endocapillary level and with formation of extracapillary crescents.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 734 "Ancho" => 975 "Tamanyo" => 214020 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Skin biopsy. 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Year/Month | Html | Total | |
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2024 November | 2 | 3 | 5 |
2024 October | 48 | 36 | 84 |
2024 September | 40 | 31 | 71 |
2024 August | 62 | 61 | 123 |
2024 July | 53 | 21 | 74 |
2024 June | 71 | 38 | 109 |
2024 May | 69 | 38 | 107 |
2024 April | 55 | 35 | 90 |
2024 March | 42 | 25 | 67 |
2024 February | 34 | 38 | 72 |
2024 January | 45 | 22 | 67 |
2023 December | 30 | 31 | 61 |
2023 November | 51 | 22 | 73 |
2023 October | 47 | 46 | 93 |
2023 September | 28 | 22 | 50 |
2023 August | 45 | 24 | 69 |
2023 July | 35 | 29 | 64 |
2023 June | 36 | 14 | 50 |
2023 May | 60 | 34 | 94 |
2023 April | 37 | 20 | 57 |
2023 March | 67 | 31 | 98 |
2023 February | 48 | 48 | 96 |
2023 January | 55 | 15 | 70 |
2022 December | 69 | 32 | 101 |
2022 November | 57 | 30 | 87 |
2022 October | 60 | 45 | 105 |
2022 September | 50 | 42 | 92 |
2022 August | 46 | 40 | 86 |
2022 July | 41 | 42 | 83 |
2022 June | 61 | 34 | 95 |
2022 May | 56 | 36 | 92 |
2022 April | 48 | 39 | 87 |
2022 March | 64 | 51 | 115 |
2022 February | 51 | 43 | 94 |
2022 January | 35 | 26 | 61 |
2021 December | 42 | 39 | 81 |
2021 November | 37 | 27 | 64 |
2021 October | 57 | 36 | 93 |
2021 September | 56 | 29 | 85 |
2021 August | 50 | 40 | 90 |
2021 July | 38 | 38 | 76 |
2021 June | 28 | 32 | 60 |
2021 May | 50 | 46 | 96 |
2021 April | 125 | 79 | 204 |
2021 March | 55 | 55 | 110 |
2021 February | 42 | 13 | 55 |
2021 January | 36 | 20 | 56 |
2020 December | 35 | 23 | 58 |
2020 November | 35 | 16 | 51 |
2020 October | 22 | 22 | 44 |
2020 September | 23 | 24 | 47 |
2020 August | 56 | 19 | 75 |
2020 July | 29 | 19 | 48 |
2020 June | 20 | 17 | 37 |
2020 May | 30 | 10 | 40 |
2020 April | 23 | 21 | 44 |
2020 March | 34 | 9 | 43 |
2020 February | 27 | 23 | 50 |
2020 January | 40 | 18 | 58 |
2019 December | 47 | 25 | 72 |
2019 November | 31 | 18 | 49 |
2019 October | 23 | 10 | 33 |
2019 September | 26 | 13 | 39 |
2019 August | 17 | 14 | 31 |
2019 July | 27 | 16 | 43 |
2019 June | 27 | 15 | 42 |
2019 May | 28 | 25 | 53 |
2019 April | 80 | 31 | 111 |
2019 March | 34 | 24 | 58 |
2019 February | 30 | 15 | 45 |
2019 January | 32 | 17 | 49 |
2018 December | 130 | 41 | 171 |
2018 November | 250 | 15 | 265 |
2018 October | 173 | 19 | 192 |
2018 September | 70 | 17 | 87 |
2018 August | 44 | 16 | 60 |
2018 July | 49 | 9 | 58 |
2018 June | 49 | 15 | 64 |
2018 May | 65 | 15 | 80 |
2018 April | 84 | 8 | 92 |
2018 March | 59 | 6 | 65 |
2018 February | 89 | 7 | 96 |
2018 January | 72 | 13 | 85 |
2017 December | 82 | 14 | 96 |
2017 November | 53 | 7 | 60 |
2017 October | 33 | 9 | 42 |
2017 September | 57 | 10 | 67 |
2017 August | 55 | 9 | 64 |
2017 July | 69 | 4 | 73 |
2017 June | 41 | 6 | 47 |
2017 May | 47 | 8 | 55 |
2017 April | 32 | 6 | 38 |
2017 March | 37 | 9 | 46 |
2017 February | 29 | 6 | 35 |
2017 January | 26 | 7 | 33 |
2016 December | 32 | 2 | 34 |
2016 November | 52 | 15 | 67 |
2016 October | 59 | 5 | 64 |
2016 September | 86 | 2 | 88 |
2016 August | 76 | 7 | 83 |
2016 July | 25 | 2 | 27 |