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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#44;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The association of nephrotic syndrome that was presented with IgA nephropathy &#40;IgA-N&#41; and malignancy has been previously reported&#46;</p><p class="elsevierStylePara">IgA &#8211;N was first described by Berger and Hinglais in 1968&#46; It is now generally known to be the most common cause of primary glomerulonephritis worldwide and is characterized by mesangial proliferation and deposition of IgA&#46;<span class="elsevierStyleSup">1</span> Malignancies that have been reported to be associated with IgA-N include Hodgkin&#8217;s disease&#44;<span class="elsevierStyleSup">2</span> and non-Hodgkin lymphoma<span class="elsevierStyleSup">3</span> renal cell carcinoma&#44;<span class="elsevierStyleSup">4</span> cancers of the lung&#44;<span class="elsevierStyleSup">5</span> larynx and esophagus&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">We report a case of IgA-N presented with the recurrence of gastric adenocarcinoma in a 58 year-old patient&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">A 58 year-old man admitted to our hospital in September 2010 with distension of the abdomen and involuntary loss of his &#37;10 weight in the last three months&#46; There were no abnormalities in urine examination on the first evaluation&#46; Upper gastrointestinal endoscopy showed gastric mass and endoscopic biopsy revealed gastric adenocarcinoma&#46; Since diagnosed with stage 3B gastric adenocarcinoma&#44; the chemoradiotherapy &#40;4 cycles of 5-fluorouracil and folinic acid with 50 Gy radiotherapy&#41; was administered after the surgery&#46; Complete remission was achieved and he has been considered for follow-up with three months interval without chemotherapy&#46; He was admitted to our hospital with dyspnea and edema in January 2012&#46; Hypoalbuminemia and 4 gram proteinuria was revelaed in laboratory examination&#46; PET-CT scan was showed pleural effusion&#44; bone metastasis and recurrence in mediastinal and abdominal lymph nodes&#46; Then he was considered recurrence of the disease and reevaluated as stage 4 gastric adenocarcinoma&#46; According to his performance status&#44; chemotherapy was not considered and he was referred to our nephrology department for nephrotic syndrome&#46; His blood pressure&#44; temperature and pulse rate were normal&#46; Physical examination revealed decreased breath sound over the right and left lower lung areas and severe edema in both lower extremities&#46; Routine laboratory tests showed the following&#58; serum levels of sodium 137mmol&#47;L&#44; potassium&#58; 5&#46;8mmol&#47;L&#44; calcium&#58; 7&#46;6mg&#47;dL and phosphate&#58; 2&#46;9mg&#47;dL&#46; Blood urea nitrogen &#40;BUN&#41; 22mg&#47;dL&#44; serum creatinine 1&#46;5mg&#47;dL&#44; serum albumin 1&#46;4g&#47;dL and hemoglobin 11&#46;8g&#47;dL&#46; Liver function parameters were within their normal limits&#46; Urinalysis showed urine red blood cells &#40;RBC&#41; counts were &#62;100&#47;high power field&#44; and urinary protein excretion was 3&#46;5g&#47;day&#46; Antinuclear antibody&#44; anti-DNA&#44; anti-streptolysin O&#44; anti-neutrophil cytoplasmic antibody&#44; anti-glomerular basement membrane antibody&#44; anti-HBs&#44; and anti-HCV were all negative&#46; Complement factors C3 and C4 were within normal ranges&#46; Serum and urine protein electrophoresis were negative for monoclonal gammopathy&#46; The peripheral blood smear was normal with no schistocytes&#46;</p><p class="elsevierStylePara">Renal biopsy was performed and in total 14 glomeruli were obtained and evaluated&#46; Light microscopy showed that one of the glomeruli had global sclerosis and other glomeruli had mesangial proliferation<span class="elsevierStyleItalic">&#46; </span>Immunohistochemically&#44; focal segmental mesangial IgA deposition was seen in three glomeruli &#40;Figure 1&#41;&#46; Steroid therapy with 1mg&#47;kg&#47;day metilprednisolone and losartan 50mg&#47;daily were started and steroid dose was reduced gradually&#46; After six months later&#44; edema was completely regressed and serum albumin level was 3&#46;0dL&#46; Additionally&#44; urinalysis showed only 1-2 RBC and proteinuria was 0&#46;2g&#47;day &#40;Table 1&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Malignancy associated nephrotic syndrome has been described in the literature by Lee et al&#46; reported that nephrotic syndrome occurring simultaneously with malignancy was 10 times higher than in the general population&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Paraneoplastic syndrome may be suspected in the presence of the following criteria&#58; &#40;a&#41; no evident etiology for the associated syndrome&#59; &#40;b&#41; the diagnosis of the syndrome and cancer simultaneously&#59; &#40;c&#41; clinical &#40;and histological&#41; remission after full remission achieved by chemotherapy or complete surgical removal of the tumor&#59; &#40;d&#41; increases of associated symptoms with tumor recurrence&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Different types of glomerulopathies&#44; generally membranous glomerulonephritis have been associated with solid tumors&#46;<span class="elsevierStyleSup">8</span> However paraneoplastic IgA-N has been reported rarely&#46;</p><p class="elsevierStylePara">Primarily&#44; IgA-N associations with cancer of the buccal cavity&#44; the nasopharynx and the respiratory tract have been described&#46; Mesangial IgA deposits have been found at autopsy in patients who died of a gastro-intestinal neoplasia without prior clinical evidence of nephropathy&#46;<span class="elsevierStyleSup">9</span> Despite intensive investigation&#44; the mechanism underlying glomerular IgA deposition in IgA nephropathy has not been clarified&#46;<span class="elsevierStyleSup">10</span> There are two isotype subclasses of IgA&#58; IgA1 and IgA2&#46; Gastrointestinal and respiratory tracts plasma cells produce both IgA1 and IgA2&#59; however plasma cells in the spleen&#44; lymph nodes and bone marrow produce predominantly IgA1&#46; Invasion of the intestinal mucosa by malignancy increases the circulating IgA level and therefore leads to the formation of mesangial deposits&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">In conclusion&#44; paraneoplastic IgA nephropathy with nephrotic syndrome could be a clinical problem in patients with malignancies&#44; besides the treatment chart has not been well-decumented yet&#46; To the best of our knowledge&#44; we report the first case of paraneoplastic IgA-N associated with recurrence of gastric adenocarcinoma&#46; IgA-N should take into account in patients with malignancy and nephrotic syndrome even if primary disease was on remission and it could be a harbinger for the relapse of disease&#46;</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 declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12266&#95;16025&#95;50533&#95;en&#95;t1122662&#46;jpg" class="elsevierStyleCrossRefs"><img src="12266_16025_50533_en_t1122662.jpg" alt="Change in serum albumin&#44; creatinine and proteinuria levels after treatment at different times"></img></a></p><p class="elsevierStylePara">Table 1&#46; Change in serum albumin&#44; creatinine and proteinuria levels after treatment at different times</p><p class="elsevierStylePara"><a href="grande&#47;12266&#95;16025&#95;50534&#95;en&#95;f112266&#46;jpg" class="elsevierStyleCrossRefs"><img src="12266_16025_50534_en_f112266.jpg" alt="Focal segmental mesangial IgA deposition in three glomeruli&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Focal segmental mesangial IgA deposition in three glomeruli&#46;</p>"
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