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with anti-myeloperoxidase specificity &#40;ANCA-MPO&#41;&#46; However&#44; the patient&#39;s condition started to improve spontaneously under conservative treatment&#44; which allowed us to delay the renal biopsy until after the lactation period&#46; The subsequent histopathological study described sclerosis in 40&#37; of the sample&#44; with obliteration of capillary lumens due to mesangial proliferation and endotheliosis&#44; increase in mesangial material and capsular adhesions&#46; Parietal epithelial cells were especially prominent and formed fibrous epithelial crescents in 4 glomeruli &#40;30&#37; of the sample&#41;&#46; On the other hand&#44; podocytes were very swollen with numerous protein reabsorption droplets&#46; Predominantly lymphocytic inflammatory deposits and mild focal fibrosis were observed in the interstitium&#46; Immunofluorescence revealed small diffuse deposits of IgG and C3 located in the mesangium with an intensity of 1&#43; &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">Based on these data&#44; 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Self-limiting p-ANCA positive vasculitis in patient with pre-eclampsia
Vasculitis p-ANCA (+) autolimitada en paciente con preeclampsia
Carlos Mañero-Rodrígueza, Limber I. Rojas-Péreza, José L. Rosalesb, Mercedes Cabac, Mercedes Gómez-Moralesc, Antonio Navas-Parejo Casadoa
a Servicio de Nefrología, Hospital Universitario San Cecilio, Granada,
b Servicio de Reumatología, Hospital Universitario San Cecilio, Granada,
c Departamento de Anatomía Patológica, Facultad de Medicina. Universidad de Granada, Granada,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">Preeclampsia is a common complication of pregnancy &#40;3&#37;-10&#37;&#41; which is defined by the development of high blood pressure and proteinuria beginning at week 20 of the pregnancy&#46; It is associated with a number of factors&#58; family history&#44; thrombophilia&#44; diabetes&#44; etc&#46;<span class="elsevierStyleSup">1&#44;2</span></p><p class="elsevierStylePara">With this in mind&#44; we present the case of a 33 year old patient with a history of pulmonary thromboembolism&#44; testing negative for blood clotting disorders &#40;including lupus anticoagulant and anti-cardiolipin&#41; but presenting a heterozygous deficiency in methylenetetrahydrofolate reductase enzyme gene &#40;C677T&#41; who developed partial HELLP syndrome during week 34 of gestation&#46; The treatment approach consisted of administering hydralazine and alpha-methyldopa&#44; and in the end&#44; an emergency caesarean section&#46; However&#44; clinical resolution was only partial &#40;with residual proteinuria of 113mg&#47;dl in 24 hour urine sample&#41;&#46;</p><p class="elsevierStylePara">Four months later &#40;during the lactation period&#41;&#44; the patient suffered a new episode&#44; characterised by inflammation in both ankles&#44; hypertension and decreased renal function with no oliguria &#40;urea 145mg&#47;dl&#44; creatinine 4&#46;3mg&#47;dl&#41; and was then admitted in the nephrology department&#46; Relevant test results were haemoglobin&#58; 9&#46;5g&#47;dl&#59; albumin&#58; 4&#46;3g&#47;dl&#59; microhaematuria&#59; and proteinuria of 125mg&#47;dl&#46; The immunology study showed that she was positive for antinuclear antibodies &#40;ANA 2&#46;02 at titres of 1&#58;80&#41; with normal anti-DNA antibodies&#44; antihistone antibodies and a complement levels&#46; Anti-cytoplasmic antibodies &#40;ANCA&#41; were positive at low titres &#40;26&#46;4U&#47;l&#41; with anti-myeloperoxidase specificity &#40;ANCA-MPO&#41;&#46; However&#44; the patient&#39;s condition started to improve spontaneously under conservative treatment&#44; which allowed us to delay the renal biopsy until after the lactation period&#46; The subsequent histopathological study described sclerosis in 40&#37; of the sample&#44; with obliteration of capillary lumens due to mesangial proliferation and endotheliosis&#44; increase in mesangial material and capsular adhesions&#46; Parietal epithelial cells were especially prominent and formed fibrous epithelial crescents in 4 glomeruli &#40;30&#37; of the sample&#41;&#46; On the other hand&#44; podocytes were very swollen with numerous protein reabsorption droplets&#46; Predominantly lymphocytic inflammatory deposits and mild focal fibrosis were observed in the interstitium&#46; Immunofluorescence revealed small diffuse deposits of IgG and C3 located in the mesangium with an intensity of 1&#43; &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">Based on these data&#44; we prescribed combination therapy with prednisone 1mg&#47;kg&#47;day and azathioprine 2mg&#47;kg&#47;day&#46; Progress remained favourable&#59; anaemia was corrected and renal function returned to normal levels &#40;urea 41&#46;2mg&#47;dl&#44; creatinine&#58; 1mg&#47;dl&#41;&#44; as did autoantibody levels&#46; However&#44; the 24 hour urine test still revealed microhaematuria and proteinuria &#40;203&#46;5mg&#47;dl&#41;&#46; In order to screen for a possible pulmonary disorder&#44; which is common in microangiopathies&#44; pulmonary function tests were performed which showed decreased alveolar diffusion due to the capillary action&#46;</p><p class="elsevierStylePara">Lastly&#44; we re-considered the definitive diagnosis for this case based on the following premises&#58; lack of criteria sufficient to indicate lupus or microscopic polyangiitis&#59; self-limiting renal disease&#59; lack of immunological specificity &#40;concomitant presence of ANA and p-ANCA&#41;&#59; histological changes partially compatible with preeclamptic damage &#40;such as endotheliosis&#44; mesangial proliferation and even interstitial fibrosis&#41;&#59; and most of all&#44; the course of the disease being related to childbirth&#46;<span class="elsevierStyleSup">3</span> The final diagnosis was drug-induced p-ANCA vasculitis in conjunction with toxaemia&#46; In this case&#44; systemic symptoms may have been related to prior intake of hydralazine and&#47;or methyldopa&#46; In addition&#44; its episodic nature fully coincides with the autoimmunity-promoting effect described in the literature for both drugs&#59; in the case of hydralazine&#44; this also seems to be linked to the development of some types of pulmonary-renal syndrome and ANCA-positive pauci immune glomerulonephritis&#46;<span class="elsevierStyleSup">4&#44;5</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11157&#95;19157&#95;29361&#95;en&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11157_19157_29361_en_f1.jpg" alt="Renal Biopsy&#46; Preeclamptic lesions and fibrous crescents"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Renal Biopsy&#46; Preeclamptic lesions and fibrous crescents</p>"
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Nefrología (English Edition)