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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#58;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The kidney and the eye&#44; with their characteristic vascular anatomy&#44; are vulnerable to vasculitis syndromes like antineutrophil cytoplasmic antibodies &#40;ANCA&#41; associated small vessel vasculitis<span class="elsevierStyleSup">1-3</span>&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Here we present a case of a 44 year old male patient complained of asthenia for one month&#46; Two weeks before he developed bilateral subconjunctival hemorrhage without photophobia or ocular pain&#46; The patient denied epistaxis&#44; hemoptysis&#44; abdominal pain&#44; arthralgias or myalgias&#46; On examination he had subconjunctival bleeding due to bilateral difuse episcleritis &#40;Figure 1&#41;&#46; There were no cardiopulmonary auscultatory findings&#44; no purpura and no signs of arthritis&#46; The patient past medical history was remarkable for chronic sinusitis with frequent episodes of epistaxis&#46; The blood panel showed severe azotemia &#40;serum creatinine 11&#44;2 mg&#47;dl&#44; BUN 100 mg&#47;dl&#41;&#44; normocytic normochromic anaemia &#40;Hb 11&#44;3 g&#47;dl&#59; Ht 33&#44;3&#37;&#41;&#44; C-reactive protein 16&#44;9 mg&#47;L&#160; &#40;0-10 mg&#47;L&#41;&#44; active urinary sediment &#40;30 red blood cells per high-power field&#44; 4 red blood cell casts&#41;&#44; and a 24 hour proteinuria of 2&#44;2 g&#46; Renal imaging revealed normal size kidneys and normal corticomedular diferentiation&#46; Hemodialysis was initiated due to uremic syndrome&#46; Chest x-ray and chest CT scan did not show any evidence of active disease in the lower respiratory tract&#46; Nasal sinus CT scan was compatible with a previous history of chronic sinusitis involving right etmoidal and both maxillary sinus&#46; Nasal mucosa biopsy showed a non-specific inflammatory process&#46; Serologic panel was negative for HIV1 and 2&#44; HBV and HCV infection&#44; complement fractions were within normal range&#46; The immunological study was positive for circulating C-ANCA with anti-proteinase 3 &#40;PR3&#41; activity confirmed by enzimatic imunoassay &#40;ELISA&#41;&#44; and negative for anti-nuclear&#44; anti DNAds and anti- glomerular basement membrane &#40;anti-GBM&#41; antibodies&#46; The renal biopsy revealed a segmentar necrotizing glomerulonephritis with circumferential crescents in more than 80&#37; of glomeruli &#40;Figure 2&#41;&#46; Immunofluorescence microscopy was compatible with a pauci-imune glomerulonephritis The above investigation confirmed the diagnosis of ANCA associated small vessel vasculitis and the patient initiated treatment with cyclophosphamide &#40;100 mg id po&#41;&#44; methylprednisolone &#40;1 g id ev&#41; changed to prednisolone &#40;70 mg id po&#41; after 3 days&#44; and prophylactic antibiotherapy with trimethoprim&#47;sulfamethoxazole&#46; On hospital day four&#44; he had a complete remission of the oftalmic disease&#44; maintaining severe renal failure&#46; Three months later&#44; our patient remained on hemodialysis due to severe azotemia&#44; without glomerular hematuria&#46; Since renal function did not recover and there was no evidence of active extrarenal disease&#44; immunesupressors were discontinued&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors present a case report of systemic vasculitis associated with ANCAs with specificity for anti-proteinase 3 &#40;PR3&#41;&#44; with renal&#44; upper respiratory tract and eye involvement suggestive of Wegener granulomatosis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The specificity of ANCA and its role on prognosis was shown by a retrospective study by Sven Weidner&#44; involving 80 patients with confirmed pathological diagnosis of pauci-imune glomerulonephritis&#46; In this study&#44; patients with PR3 ANCAs had a higher risk of progressing to end-stage renal disease &#40;ESRD&#41;<span class="elsevierStyleSup">4</span>&#46;The patient in our case report&#44; besides having PR3 ANCAs&#44; also presented with a pre-treatment serum creatinine above 500 &#181;mol&#47;L &#40;5&#44;7 mg&#47;dl&#41;&#44; which also predicts a worse outcome<span class="elsevierStyleSup">4</span>&#46; As for the type and number of crescents&#44; the presence of circumferencial crescents in more than 80&#37; of glomeruli&#44; determines a dismal prognosis&#44; indicating a worse response to immunesupressor treatment<span class="elsevierStyleSup">5</span>&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our case report illustrates that an uncommon extra-renal involvement like an episcleritis&#44; can be the form of presentation of a systemic disease with lethal potential&#46; &#160;Although the prognosis in terms of progression for ESRD is mainly determined by the renal histology&#44; the type of ANCA involved and serum creatinine value when treatment is begun&#44; the patient survival is still dependent on the level of clinical suspicion leading to an early diagnosis and treatment&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10753&#95;108&#95;11307&#95;en&#95;10753&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10753_108_11307_en_10753_f1.jpg" alt="Subconjunctival bleeding due to difuse episcleritis&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Subconjunctival bleeding due to difuse episcleritis&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10753&#95;108&#95;11308&#95;en&#95;10753&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10753_108_11308_en_10753_f2.jpg" alt="Cellular circumferential crescents in more than 80&#37; of glomeruli &#40;Silver stain&#44; x100&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Cellular circumferential crescents in more than 80&#37; of glomeruli &#40;Silver stain&#44; x100&#41;&#46;</p>"
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A patient with acute renal failure and episcleritis, is there more than meets the eye?
Paciente con insuficiencia renal aguda y episcleritis, ¿hay en ello más de lo que se ve?
, A.P.. Bernardob, J.M.. Montalbánb, E.. Rochab
b Department of Nephrology, Hospital Amato Lusitano, Castelo Branco, Castelo Branco, Portugal,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#58;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The kidney and the eye&#44; with their characteristic vascular anatomy&#44; are vulnerable to vasculitis syndromes like antineutrophil cytoplasmic antibodies &#40;ANCA&#41; associated small vessel vasculitis<span class="elsevierStyleSup">1-3</span>&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Here we present a case of a 44 year old male patient complained of asthenia for one month&#46; Two weeks before he developed bilateral subconjunctival hemorrhage without photophobia or ocular pain&#46; The patient denied epistaxis&#44; hemoptysis&#44; abdominal pain&#44; arthralgias or myalgias&#46; On examination he had subconjunctival bleeding due to bilateral difuse episcleritis &#40;Figure 1&#41;&#46; There were no cardiopulmonary auscultatory findings&#44; no purpura and no signs of arthritis&#46; The patient past medical history was remarkable for chronic sinusitis with frequent episodes of epistaxis&#46; The blood panel showed severe azotemia &#40;serum creatinine 11&#44;2 mg&#47;dl&#44; BUN 100 mg&#47;dl&#41;&#44; normocytic normochromic anaemia &#40;Hb 11&#44;3 g&#47;dl&#59; Ht 33&#44;3&#37;&#41;&#44; C-reactive protein 16&#44;9 mg&#47;L&#160; &#40;0-10 mg&#47;L&#41;&#44; active urinary sediment &#40;30 red blood cells per high-power field&#44; 4 red blood cell casts&#41;&#44; and a 24 hour proteinuria of 2&#44;2 g&#46; Renal imaging revealed normal size kidneys and normal corticomedular diferentiation&#46; Hemodialysis was initiated due to uremic syndrome&#46; Chest x-ray and chest CT scan did not show any evidence of active disease in the lower respiratory tract&#46; Nasal sinus CT scan was compatible with a previous history of chronic sinusitis involving right etmoidal and both maxillary sinus&#46; Nasal mucosa biopsy showed a non-specific inflammatory process&#46; Serologic panel was negative for HIV1 and 2&#44; HBV and HCV infection&#44; complement fractions were within normal range&#46; The immunological study was positive for circulating C-ANCA with anti-proteinase 3 &#40;PR3&#41; activity confirmed by enzimatic imunoassay &#40;ELISA&#41;&#44; and negative for anti-nuclear&#44; anti DNAds and anti- glomerular basement membrane &#40;anti-GBM&#41; antibodies&#46; The renal biopsy revealed a segmentar necrotizing glomerulonephritis with circumferential crescents in more than 80&#37; of glomeruli &#40;Figure 2&#41;&#46; Immunofluorescence microscopy was compatible with a pauci-imune glomerulonephritis The above investigation confirmed the diagnosis of ANCA associated small vessel vasculitis and the patient initiated treatment with cyclophosphamide &#40;100 mg id po&#41;&#44; methylprednisolone &#40;1 g id ev&#41; changed to prednisolone &#40;70 mg id po&#41; after 3 days&#44; and prophylactic antibiotherapy with trimethoprim&#47;sulfamethoxazole&#46; On hospital day four&#44; he had a complete remission of the oftalmic disease&#44; maintaining severe renal failure&#46; Three months later&#44; our patient remained on hemodialysis due to severe azotemia&#44; without glomerular hematuria&#46; Since renal function did not recover and there was no evidence of active extrarenal disease&#44; immunesupressors were discontinued&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors present a case report of systemic vasculitis associated with ANCAs with specificity for anti-proteinase 3 &#40;PR3&#41;&#44; with renal&#44; upper respiratory tract and eye involvement suggestive of Wegener granulomatosis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The specificity of ANCA and its role on prognosis was shown by a retrospective study by Sven Weidner&#44; involving 80 patients with confirmed pathological diagnosis of pauci-imune glomerulonephritis&#46; In this study&#44; patients with PR3 ANCAs had a higher risk of progressing to end-stage renal disease &#40;ESRD&#41;<span class="elsevierStyleSup">4</span>&#46;The patient in our case report&#44; besides having PR3 ANCAs&#44; also presented with a pre-treatment serum creatinine above 500 &#181;mol&#47;L &#40;5&#44;7 mg&#47;dl&#41;&#44; which also predicts a worse outcome<span class="elsevierStyleSup">4</span>&#46; As for the type and number of crescents&#44; the presence of circumferencial crescents in more than 80&#37; of glomeruli&#44; determines a dismal prognosis&#44; indicating a worse response to immunesupressor treatment<span class="elsevierStyleSup">5</span>&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our case report illustrates that an uncommon extra-renal involvement like an episcleritis&#44; can be the form of presentation of a systemic disease with lethal potential&#46; &#160;Although the prognosis in terms of progression for ESRD is mainly determined by the renal histology&#44; the type of ANCA involved and serum creatinine value when treatment is begun&#44; the patient survival is still dependent on the level of clinical suspicion leading to an early diagnosis and treatment&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10753&#95;108&#95;11307&#95;en&#95;10753&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10753_108_11307_en_10753_f1.jpg" alt="Subconjunctival bleeding due to difuse episcleritis&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Subconjunctival bleeding due to difuse episcleritis&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10753&#95;108&#95;11308&#95;en&#95;10753&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10753_108_11308_en_10753_f2.jpg" alt="Cellular circumferential crescents in more than 80&#37; of glomeruli &#40;Silver stain&#44; x100&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Cellular circumferential crescents in more than 80&#37; of glomeruli &#40;Silver stain&#44; x100&#41;&#46;</p>"
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