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    "textoCompleto" => "<p class="elsevierStylePara"> A 73-year-old male patient was referred to our Nephrology department with acute renal failure in the context of constitutional syndrome&#46; His serum creatinine level was 4&#46;9 mg&#47;dL at the time of referral&#46;</p><p class="elsevierStylePara"> The patient had a 10-year history of hypertension&#44; which was well controlled with losartan&#47;hydrochlorothiazide &#40;100&#160;mg&#47;25&#160;mg per day&#41;&#46; He was also taking tamsulosin &#40;0&#46;4&#160;mg per day&#41; for benign prostatic hypertrophy&#44; which was monitored by his urologist&#46;</p><p class="elsevierStylePara"> For the last 8 months&#44; the patient had had a dry cough&#44; accompanied by asthenia&#44; anorexia and a weight loss of 6&#160;kilograms&#46; In view of the constitutional syndrome with cough&#44; outpatient investigations had been undertaken&#44; showing an initial creatinine level of 3&#46;5 mg&#47;dL&#44; which increased to 4&#46;9&#160;mg&#47;dL 10 days later&#46; Renal ultrasound revealed normalsized kidneys with correct corticomedullary differentiation&#44; and a thoracic CT scan showed lesions compatible with two pulmonary masses&#46; One was located in the anterobasal segment of the left lower lobe &#40;LLL&#41; and measured approximately 5 &#215; 4&#160;cm&#46; The other was located in the posterobasal segment of the right lower lobe &#40;RLL&#41;&#44; measured approximately 4 &#215; 3&#160;cm&#44; had poorly-defined edges&#44; and an air bronchogram in its interior&#46; There was also slight peripheral infiltrate in the apical region of the RLL&#44; with a non-specific inflammatory appearance&#46; Another finding of note was the presence of mediastinal lymphadenopathies&#46; A bronchoscopy was then performed&#44; showing moderate infiltration of the subsegmental spur of the right basal segment&#44; which was biopsied&#46; Bronchial aspirate samples were taken for microbiology and cytology&#46; Ziehl-Neelsen staining was negative&#46; An attempt to perform a fine-needle aspiration biopsy of one of the pulmonary masses was unsuccessful due to technical problems&#59; therefore&#44; an in-patient mediastinoscopy was arranged with the Thoracic Surgery Department&#46;</p><p class="elsevierStylePara"> Finally&#44; the patient was admitted to the Nephrology Department for study&#44; diagnosis and treatment of acute renal failure&#44; with progressive deterioration of renal function associated with pulmonary and lymph node involvement of unknown origin&#46; On admission&#44; the patient&#8217;s blood pressure was normal and no enlarged cervical&#44; axillary or femoral lymph nodes were palpated&#46; The only observation of note was the patient&#8217;s emaciated appearance&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Further investigations </span></p><p class="elsevierStylePara"> Blood test results showed pancytopenia&#44; leucocytes 3&#44;100 &#215; 10<span class="elsevierStyleSup">9</span>&#47;L&#44; haemoglobin 10&#46;1 g&#47;dL&#44; haematocrit 28&#46;9&#37;&#44; and platelets 117&#44;000 &#215; 10<span class="elsevierStyleSup">9</span>&#47;L&#46; The patient&#8217;s renal function had deteriorated&#44; with serum creatinine reaching 6&#46;64 mg&#47;dL &#40;MDRD-eGFR 8&#160;ml&#47; min&#41;&#46; The urine protein-to-creatinine ratio was 638 mg&#47;g and there was no evidence of microhaematuria&#46; The immunology study showed an increased IgG and complement utilisation through classical pathway activation&#58; IgG &#61; 3&#44;770 &#40;700-1&#44;400&#41;&#44; C3&#47;C4 &#61; 33 mg&#47;dL &#40;90-180&#41;&#47;&#60;1 mg&#47;dL &#40;10-40&#41;&#46; A&#160;subsequent analysis of IgG subclasses revealed that the increase was mainly in IgG4&#58; IgG1&#47;IgG2&#47; IgG3&#47;IgG4 &#61; 1&#44;813 &#40;490-890&#41;&#47;557 &#40;189-527&#41;&#47;156 &#40;20-72&#41;&#47;1&#44;244 &#40;18-85&#41; mg&#47;dL&#46;</p><p class="elsevierStylePara"> The protein analysis showed beta-gamma bridging&#46; The bone marrow aspirate ruled out monoclonal gammopathies&#46;</p><p class="elsevierStylePara"> We repeated the thoracic CT scan and confirmed the previously described pulmonary nodular images and mediastinal lymphadenopathies&#46; The thoracic surgeons performed a mediastinoscopy with lymph node biopsy&#59; lymphomatous disease was ruled out in the histology report&#46;</p><p class="elsevierStylePara"> Lastly&#44; in view of the unknown origin of the patient&#8217;s progressive renal failure&#44; a renal biopsy was taken&#44; and this led to the final diagnosis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anatomic pathology study of the renal biopsy </span></p><p class="elsevierStylePara"> Dense&#44; diffuse inflammatory infiltrate was observed in the cortical and medullary interstitial space&#44; with abundant plasma cells and lymphocytes&#44; and some eosinophils&#44; as well as diffuse interstitial fibrosis &#40;affecting over 50&#37; of the cortical tissue&#41; and tubular atrophy&#46; The fibrosis had a focal storiform pattern - whereby the fibroblasts are arranged in bundles resembling the whorls of a straw mat - surrounding cell nests of lymphocytes and&#47;or plasma cells&#46;</p><p class="elsevierStylePara"> Of the 15 glomeruli present in the sample&#44; 9 were sclerosed and the rest had normal cells&#44; with a slight mesangial matrix expansion&#46; Some thick&#44; folded basement membranes were observed segmentally&#46; The interlobular arteries presented a narrowed lumen caused by marked fibrosis of their inner layer&#46;</p><p class="elsevierStylePara"> Immunofluorescence assay showed granular positivity for IgG&#44; kappa&#44; lambda and C3 &#40;all with intensity 3&#43;&#41; in the tubular basement membranes and in the Bowman capsule&#46; The 3 glomeruli in the sample were negative for IgG&#44; IgA&#44; IgM&#44; C3&#44; C1q&#44; kappa and lambda&#46;</p><p class="elsevierStylePara"> The immunohistochemical IgG4 study showed 10 to 20 IgG4&#43; plasma cells per high power field&#46; The lymph cell infiltrate was predominantly T type&#46;</p><p class="elsevierStylePara"> The ultrastructural examination identified abundant electron-dense and amorphous deposits in the interior of thickened tubular basement membranes&#46; The only glomerulus in the ultrastructural study sample had thick&#44; folded basement membranes&#44; with a slight fusion of the podocytes&#46; No electron-dense deposits were observed&#46;</p><p class="elsevierStylePara"><img alt="Figure 1 – Expansile interstitial fibrosis with a storiform pattern&#44; tubular atrophy and destruction&#44; and inflammatory infiltrate &#40;Masson trichrome x200&#41;" src="498v35n02-90412431fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1 &#8211; Expansile interstitial fibrosis with a storiform pattern&#44; tubular atrophy and destruction&#44; and inflammatory infiltrate &#40;Masson trichrome x200&#41;</span></p><p class="elsevierStylePara"><img alt="Figure 2 – Inflammatory infiltrate comprised of plasma cells&#44; lymphocytes and some eosinophils &#40;H&#38;E x200&#41;" src="498v35n02-90412431fig2.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 2 &#8211; Inflammatory infiltrate comprised of plasma cells&#44; lymphocytes and some eosinophils &#40;H&#38;E x200&#41;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anatomic pathology study of the mediastinal lymph node biopsies </span></p><p class="elsevierStylePara"> The lymph nodes showed paracortical and follicular hyperplasia changes&#44; as well as abundant plasma cell infiltrate&#46;</p><p class="elsevierStylePara"> The immunohistochemical analysis confirmed that the plasma cells were polyclonal&#59; kappa and lambda light chains were positive&#46; Staining showed more than 100 IgG4&#43; plasma cells per high power field&#46;</p><p class="elsevierStylePara"><img alt="Figure 3 – Immunofluorescence for IgG with granular positivity in the tubular basement membranes and the Bowman capsule&#59; the glomerulus is negative &#40;x200&#41;" src="498v35n02-90412431fig3.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 3 &#8211; Immunofluorescence for IgG with granular positivity in the tubular basement membranes and the Bowman capsule&#59; the glomerulus is negative &#40;x200&#41;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Outcome </span></p><p class="elsevierStylePara"> The patient was treated with corticoids at a dose of 0&#46;6 mg&#47; kg&#44; which was later tapered down to 5 mg per day&#46; Despite this&#44; the patient is currently receiving haemodialysis&#44; but has a good quality of life&#44; as he is able to carry out his activities of daily living completely independently&#46; It is likely that the extensive&#44; chronic interstitial lesions seen in the biopsy contributed to the lack of renal recovery&#46; Plasma IgG4 decreased to 1&#44;074 mg&#47;dL at the beginning of treatment&#44; and was 159 mg&#47; dL 7 months later&#46; A follow-up thoracic CT scan was performed after 8 months of the corticoid treatment&#44; showing a reduction of the nodular lesions and no enlarged lymph nodes&#46;</p><p class="elsevierStylePara"><img alt="Figure 4 – Immunohistochemical IgG4 staining with increase of IgG4&#43; plasma cells in the inflammatory infiltrate &#40;x200&#41;" src="498v35n02-90412431fig4.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 4 &#8211; Immunohistochemical IgG4 staining with increase of IgG4&#43; plasma cells in the inflammatory infiltrate &#40;x200&#41;</span></p><p class="elsevierStylePara"><img alt="Figure 5 – Electron microscopy showing an atrophic tubule with thick basement membranes containing abundant electron-dense deposits &#40;x5&#44;000&#41;" src="498v35n02-90412431fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 5 &#8211; Electron microscopy showing an atrophic tubule with thick basement membranes containing abundant electron-dense deposits &#40;x5&#44;000&#41;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion </span></p><p class="elsevierStylePara"> Our patient was referred to the Nephrology Department due to acute renal failure&#44; while being investigated for pulmonary masses and mediastinal lymphadenopathies&#46; The clinical-pathological correlation of this case led to the diagnosis of IgG4 nephropathy&#46;</p><p class="elsevierStylePara"> IgG4-related disease &#40;IgG4-RD&#41; is a systemic autoimmune process that has only recently been recognised&#46; It usually presents as inflammatory masses in multiple locations&#46; It has a typical histological appearance&#44; which is similar in all affected organs&#44; characterised by a lymphoplasmacytic infiltrate rich in IgG4&#43; plasma cells&#44; storiform fibrosis&#44; and often&#44; but not always&#44; elevated serum IgG4&#46;<span class="elsevierStyleSup">1&#44;2</span> IgG4-RD was initially described in the pancreas&#44; but it can affect any organ&#46; The clinical manifestations vary depending on disease severity and organs affected&#46;</p><p class="elsevierStylePara"> IgG4-RD is more prevalent among males than females&#44; with a ratio of 3&#58;1&#44; and it is more frequent in patients over the age of 50&#46;</p><p class="elsevierStylePara"><img alt="Figure 6 – Thoracic CT scan&#58; bilateral pulmonary nodules with air bronchograms and irregular margins" src="498v35n02-90412431fig6.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 6 &#8211; Thoracic CT scan&#58; bilateral pulmonary nodules with air bronchograms and irregular margins</span></p><p class="elsevierStylePara"><img alt="Figure 7 – Thoracic CT scan after treatment&#58; resolving nodules in a follow-up CT scan 8 months later" src="498v35n02-90412431fig7.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 7 &#8211; Thoracic CT scan after treatment&#58; resolving nodules in a follow-up CT scan 8 months later</span></p><p class="elsevierStylePara"> In the kidney&#44; it can present as nodules or as diffuse infiltration in enlarged kidneys&#46;<span class="elsevierStyleSup">3</span> The diagnosis is reached by renal biopsy&#44; which shows tubulointerstitial nephritis &#40;TIN&#41; rich in plasma cells expressing IgG4&#44; with abundant eosinophils in some cases&#46; The presence of deposits in the tubular basement membranes is also a diagnostic criterion for this disease&#46;<span class="elsevierStyleSup">4</span> As TIN is non-specific&#44; it is easy to underdiagnose IgG4-RD unless an adequate clinical-pathological correlation is established&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara"> In the largest series of patients with IgG4-RD &#40;n&#61;153&#41;&#44; Saeki et al reported that approximately 20&#37; of cases had renal involvement confirmed by biopsy&#44;<span class="elsevierStyleSup">6</span> which often revealed an IgG4&#43; plasma cell-rich lymphoplasmatic infiltrate&#46; Moreover&#44; up to 70&#37; of the patients in this series had elevated serum IgG4 levels&#44; hypergammaglobulinaemia and hypocomplementaemia&#46;<span class="elsevierStyleSup">7</span> Furthermore&#44; some of these patients did not have autoimmune pancreatitis&#46;</p><p class="elsevierStylePara"> The IgG4 molecule only accounts for 5&#37; of the total concentration of IgG under normal conditions&#46; IgG4 has a wide range of plasma concentrations&#44; which range between 0&#46;01 and 1&#46;40 mg&#47;dL&#46; In contrast to those of other IgG subclasses&#44; the heavy chains &#40;Fc region&#41; of IgG4 are bound by weak disulphide bridges&#46; This facilitates IgG4 division and the formation of &#8220;hybrid&#8221; IgG4 molecules with 2 Fc and 2 light chains &#40;Fab&#41; with an affinity for different antigens&#46; This reduces their propensity to form immune complexes&#44; but they show a notable tendency to mimic rheumatoid factor activity&#44; binding to each other through the Fc&#46; IgG4 is produced when there is repeated and&#47;or prolonged exposure to certain antigens &#40;in infections and allergies&#41;&#46; IgG4 production is controlled by the T helper 2 cell response&#46;<span class="elsevierStyleSup">1</span> From an immunological standpoint&#44; our patient initially had very elevated IgG4 levels&#46; In addition&#44; we observed an activation of the classical complement pathway &#40;low C3 and C4&#41;&#44; in common with other cases&#44; and which seems to be related to the presence of circulating immune complexes&#46; The literature describes IgG4-related disease as an autoimmune pathology triggered by a reaction against certain autoantigens &#40;such as lactoferrin and carbonic anhydrase II&#41;&#46; The autoantibodies formed in the inflamed organs could bind to epithelial antigens&#44; leading to immune complex deposits on the epithelial basement membranes&#46; Furthermore&#44; although IgG4 does not activate the classical complement pathway by itself&#44; it seems that other isoforms present in the kidney &#40;such as IgG1 and IgG3&#41; could activate it&#46; Also&#44; it appears that IgG4 could activate the complement cascade through the lecithin pathway&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara"> In addition to its role in IgG4-RD&#44; IgG4 has also been associated with other diseases&#44; such as Mikulicz syndrome&#44; Riedel&#8217;s thyroiditis&#44; Ormond&#8217;s disease&#44; retroperitoneal fibrosis and inflammatory pseudotumours&#46; In the kidney&#44; IgG4-RD is manifested as TIN&#44; but there have also been cases of renal involvement in the form of membranous glomerulonephritis &#40;GN&#41; &#40;9&#37;&#41;&#44; IgA GN and nonspecific GN&#46;<span class="elsevierStyleSup">6&#44;9</span></p><p class="elsevierStylePara"> Clinically&#44; IgG4-RD manifests as constitutional syndrome&#44; with fever and elevated acute phase reactants&#44; as well as chance findings in radiographic images&#46; In cases involving the kidneys&#44; patients have proteinuria in a nonnephrotic range with or without renal failure&#46; Some patients have allergic symptoms &#40;asthma&#44; eczema&#44; atopy&#44; eosinophilia&#41; and up to 40&#37; of cases also present sinusitis and bronchial asthma&#46; Our patient had primary involvement of the lungs&#44; kidneys and mediastinal lymph nodes&#44; and his rapidly progressive renal failure was particularly striking in this context&#46;</p><p class="elsevierStylePara"> Given the rarity of the disease&#44; there is no scientific evidence regarding treatment&#44; but usually the recommended therapy is based on corticosteroids&#46;<span class="elsevierStyleSup">10</span> In general&#44; patients are treated when the lymphoplasmacytic infiltrates cause target organ dysfunction &#40;kidney dysfunction&#44; in our case&#44; led to renal failure&#41;&#46; Caution should be exercised when treating asymptomatic patients and those with only enlarged lymph nodes&#44; since the drugs involved have well-known adverse effects&#46; Glucocorticoids are administered at doses of 0&#46;6 mg&#47; kg&#44; and the dose is reduced progressively after 2 to 4 weeks&#44; leaving the patient with a prednisone dose of 2&#46;5-5 mg&#47;day for 3 years&#46; Azathioprine&#44; mycophenolate mofetil and methotrexate have been used as maintenance therapy with no clear scientific evidence&#46; There have also been some cases of resistant disease&#44; as well as recurrences&#44; which have been treated with rituximab&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara"> The key determinant of treatment response is usually the level of fibrosis of the affected organ&#46; IgG4 plasma levels do not return to normal values in 63&#37; of cases&#44; of which only 30&#37; present recurrences&#46; In some cases&#44; monitoring of IgG4 levels could be used to identify recurrences&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of Interest </span></p><p class="elsevierStylePara"> The authors have no conflicts of interest to declare&#46;</p><hr></hr><p class="elsevierStylePara"> Sent for review on 14<span class="elsevierStyleSup">th</span> August 2013 <br></br> Accepted on 2<span class="elsevierStyleSup">nd</span> January 2015</p><p class="elsevierStylePara"> &#42; <span class="elsevierStyleItalic">Corresponding author</span>&#46;<br></br> Loreto Fern&#225;ndez Lorente&#44; <br></br> Servicio de Nefrolog&#237;a&#44; Complejo Hospitalario de Navarra&#44; <br></br> Calle Irunlarrea&#44; 3&#44; 31008 Pamplona&#44; Navarra&#44; Spain&#46; <br></br> Tel&#46;&#58; 686174157<br></br><span class="elsevierStyleItalic">E-mails&#58; </span><a href="mailto&#58;ml&#46;fernandez&#46;lorente&#64;navarra&#46;es" class="elsevierStyleCrossRefs">ml&#46;fernandez&#46;lorente&#64;navarra&#46;es</a>&#59; <a href="mailto&#58;loretofer&#64;msn&#46;com" class="elsevierStyleCrossRefs">loretofer&#64;msn&#46;com</a></p>"
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        "resumen" => "<p class="elsevierStylePara"> El caso presentado es el de un paciente var&#243;n de 73 a&#241;os que debuta con un fracaso renal agudo en el contexto de infiltrados pulmonares y adenopat&#237;as mediast&#237;nicas a estudio&#46; En el an&#225;lisis de orina destac&#243; proteinuria de rango tubular&#44; sin microhematuria&#46; En el estudio inmunol&#243;gico se observ&#243; &#250;nicamente una elevaci&#243;n de los valores normales de IgG&#44; junto con una activaci&#243;n de la v&#237;a cl&#225;sica del complemento&#46; La biopsia renal y la correcta correlaci&#243;n cl&#237;nico-patol&#243;gica fueron definitivas en este caso&#44; mostrando una vez m&#225;s ser una herramienta fundamental en el diagn&#243;stico del fracaso renal agudo de etiolog&#237;a no clara&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> This is a case report of a 73-year-old man with new-onset acute renal failure while being investigated for pulmonary infiltrates and mediastinal lymphadenopathies&#46; Urine tests showed tubular range proteinuria with no microhaematuria&#46; Immunology tests showed elevated serum IgG and hypocomplementaemia &#40;classical pathway activation&#41;&#46; Renal biopsy and clinical-pathological correlation were crucial in this case&#44; reinforcing their important role in the final diagnosis of acute kidney injury&#46;</p>"
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IgG4-related disease: description of a case with pulmonary lesions, mediastinal lymphadenopathies and rapidly progressive renal failure
Enfermedad relacionada con IgG4: descripción de un caso con lesiones pulmonares, adenopatías mediastínicas e insuficiencia renal rápidamente progresiva
Loreto Fernández Lorentea, Dolores López Álvarezb, Virginia García Lópezc, Vesna Abujder Kollrosd, Aurelio Arizab, Alejandro Gálveze, Josep Bonetd
a Servicio de Nefrología, Complejo Hospitalario de Navarra, Pamplona, Navarra (Spain)
b Servicio de Anatomía Patológica, Hospital Germans Trias i Pujol, Badalona, Barcelona (Spain)
c Servicio de Inmunología, Hospital Germans Trias i Pujol, Badalona, Barcelona (Spain)
d Servicio de Nefrología, Hospital Germans Trias i Pujol, Badalona, Barcelona (Spain)
e Medicina Interna, Hospital de Calella, Calella, Barcelona (Spain)
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    "textoCompleto" => "<p class="elsevierStylePara"> A 73-year-old male patient was referred to our Nephrology department with acute renal failure in the context of constitutional syndrome&#46; His serum creatinine level was 4&#46;9 mg&#47;dL at the time of referral&#46;</p><p class="elsevierStylePara"> The patient had a 10-year history of hypertension&#44; which was well controlled with losartan&#47;hydrochlorothiazide &#40;100&#160;mg&#47;25&#160;mg per day&#41;&#46; He was also taking tamsulosin &#40;0&#46;4&#160;mg per day&#41; for benign prostatic hypertrophy&#44; which was monitored by his urologist&#46;</p><p class="elsevierStylePara"> For the last 8 months&#44; the patient had had a dry cough&#44; accompanied by asthenia&#44; anorexia and a weight loss of 6&#160;kilograms&#46; In view of the constitutional syndrome with cough&#44; outpatient investigations had been undertaken&#44; showing an initial creatinine level of 3&#46;5 mg&#47;dL&#44; which increased to 4&#46;9&#160;mg&#47;dL 10 days later&#46; Renal ultrasound revealed normalsized kidneys with correct corticomedullary differentiation&#44; and a thoracic CT scan showed lesions compatible with two pulmonary masses&#46; One was located in the anterobasal segment of the left lower lobe &#40;LLL&#41; and measured approximately 5 &#215; 4&#160;cm&#46; The other was located in the posterobasal segment of the right lower lobe &#40;RLL&#41;&#44; measured approximately 4 &#215; 3&#160;cm&#44; had poorly-defined edges&#44; and an air bronchogram in its interior&#46; There was also slight peripheral infiltrate in the apical region of the RLL&#44; with a non-specific inflammatory appearance&#46; Another finding of note was the presence of mediastinal lymphadenopathies&#46; A bronchoscopy was then performed&#44; showing moderate infiltration of the subsegmental spur of the right basal segment&#44; which was biopsied&#46; Bronchial aspirate samples were taken for microbiology and cytology&#46; Ziehl-Neelsen staining was negative&#46; An attempt to perform a fine-needle aspiration biopsy of one of the pulmonary masses was unsuccessful due to technical problems&#59; therefore&#44; an in-patient mediastinoscopy was arranged with the Thoracic Surgery Department&#46;</p><p class="elsevierStylePara"> Finally&#44; the patient was admitted to the Nephrology Department for study&#44; diagnosis and treatment of acute renal failure&#44; with progressive deterioration of renal function associated with pulmonary and lymph node involvement of unknown origin&#46; On admission&#44; the patient&#8217;s blood pressure was normal and no enlarged cervical&#44; axillary or femoral lymph nodes were palpated&#46; The only observation of note was the patient&#8217;s emaciated appearance&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Further investigations </span></p><p class="elsevierStylePara"> Blood test results showed pancytopenia&#44; leucocytes 3&#44;100 &#215; 10<span class="elsevierStyleSup">9</span>&#47;L&#44; haemoglobin 10&#46;1 g&#47;dL&#44; haematocrit 28&#46;9&#37;&#44; and platelets 117&#44;000 &#215; 10<span class="elsevierStyleSup">9</span>&#47;L&#46; The patient&#8217;s renal function had deteriorated&#44; with serum creatinine reaching 6&#46;64 mg&#47;dL &#40;MDRD-eGFR 8&#160;ml&#47; min&#41;&#46; The urine protein-to-creatinine ratio was 638 mg&#47;g and there was no evidence of microhaematuria&#46; The immunology study showed an increased IgG and complement utilisation through classical pathway activation&#58; IgG &#61; 3&#44;770 &#40;700-1&#44;400&#41;&#44; C3&#47;C4 &#61; 33 mg&#47;dL &#40;90-180&#41;&#47;&#60;1 mg&#47;dL &#40;10-40&#41;&#46; A&#160;subsequent analysis of IgG subclasses revealed that the increase was mainly in IgG4&#58; IgG1&#47;IgG2&#47; IgG3&#47;IgG4 &#61; 1&#44;813 &#40;490-890&#41;&#47;557 &#40;189-527&#41;&#47;156 &#40;20-72&#41;&#47;1&#44;244 &#40;18-85&#41; mg&#47;dL&#46;</p><p class="elsevierStylePara"> The protein analysis showed beta-gamma bridging&#46; The bone marrow aspirate ruled out monoclonal gammopathies&#46;</p><p class="elsevierStylePara"> We repeated the thoracic CT scan and confirmed the previously described pulmonary nodular images and mediastinal lymphadenopathies&#46; The thoracic surgeons performed a mediastinoscopy with lymph node biopsy&#59; lymphomatous disease was ruled out in the histology report&#46;</p><p class="elsevierStylePara"> Lastly&#44; in view of the unknown origin of the patient&#8217;s progressive renal failure&#44; a renal biopsy was taken&#44; and this led to the final diagnosis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anatomic pathology study of the renal biopsy </span></p><p class="elsevierStylePara"> Dense&#44; diffuse inflammatory infiltrate was observed in the cortical and medullary interstitial space&#44; with abundant plasma cells and lymphocytes&#44; and some eosinophils&#44; as well as diffuse interstitial fibrosis &#40;affecting over 50&#37; of the cortical tissue&#41; and tubular atrophy&#46; The fibrosis had a focal storiform pattern - whereby the fibroblasts are arranged in bundles resembling the whorls of a straw mat - surrounding cell nests of lymphocytes and&#47;or plasma cells&#46;</p><p class="elsevierStylePara"> Of the 15 glomeruli present in the sample&#44; 9 were sclerosed and the rest had normal cells&#44; with a slight mesangial matrix expansion&#46; Some thick&#44; folded basement membranes were observed segmentally&#46; The interlobular arteries presented a narrowed lumen caused by marked fibrosis of their inner layer&#46;</p><p class="elsevierStylePara"> Immunofluorescence assay showed granular positivity for IgG&#44; kappa&#44; lambda and C3 &#40;all with intensity 3&#43;&#41; in the tubular basement membranes and in the Bowman capsule&#46; The 3 glomeruli in the sample were negative for IgG&#44; IgA&#44; IgM&#44; C3&#44; C1q&#44; kappa and lambda&#46;</p><p class="elsevierStylePara"> The immunohistochemical IgG4 study showed 10 to 20 IgG4&#43; plasma cells per high power field&#46; The lymph cell infiltrate was predominantly T type&#46;</p><p class="elsevierStylePara"> The ultrastructural examination identified abundant electron-dense and amorphous deposits in the interior of thickened tubular basement membranes&#46; The only glomerulus in the ultrastructural study sample had thick&#44; folded basement membranes&#44; with a slight fusion of the podocytes&#46; No electron-dense deposits were observed&#46;</p><p class="elsevierStylePara"><img alt="Figure 1 – Expansile interstitial fibrosis with a storiform pattern&#44; tubular atrophy and destruction&#44; and inflammatory infiltrate &#40;Masson trichrome x200&#41;" src="498v35n02-90412431fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1 &#8211; Expansile interstitial fibrosis with a storiform pattern&#44; tubular atrophy and destruction&#44; and inflammatory infiltrate &#40;Masson trichrome x200&#41;</span></p><p class="elsevierStylePara"><img alt="Figure 2 – Inflammatory infiltrate comprised of plasma cells&#44; lymphocytes and some eosinophils &#40;H&#38;E x200&#41;" src="498v35n02-90412431fig2.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 2 &#8211; Inflammatory infiltrate comprised of plasma cells&#44; lymphocytes and some eosinophils &#40;H&#38;E x200&#41;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anatomic pathology study of the mediastinal lymph node biopsies </span></p><p class="elsevierStylePara"> The lymph nodes showed paracortical and follicular hyperplasia changes&#44; as well as abundant plasma cell infiltrate&#46;</p><p class="elsevierStylePara"> The immunohistochemical analysis confirmed that the plasma cells were polyclonal&#59; kappa and lambda light chains were positive&#46; Staining showed more than 100 IgG4&#43; plasma cells per high power field&#46;</p><p class="elsevierStylePara"><img alt="Figure 3 – Immunofluorescence for IgG with granular positivity in the tubular basement membranes and the Bowman capsule&#59; the glomerulus is negative &#40;x200&#41;" src="498v35n02-90412431fig3.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 3 &#8211; Immunofluorescence for IgG with granular positivity in the tubular basement membranes and the Bowman capsule&#59; the glomerulus is negative &#40;x200&#41;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Outcome </span></p><p class="elsevierStylePara"> The patient was treated with corticoids at a dose of 0&#46;6 mg&#47; kg&#44; which was later tapered down to 5 mg per day&#46; Despite this&#44; the patient is currently receiving haemodialysis&#44; but has a good quality of life&#44; as he is able to carry out his activities of daily living completely independently&#46; It is likely that the extensive&#44; chronic interstitial lesions seen in the biopsy contributed to the lack of renal recovery&#46; Plasma IgG4 decreased to 1&#44;074 mg&#47;dL at the beginning of treatment&#44; and was 159 mg&#47; dL 7 months later&#46; A follow-up thoracic CT scan was performed after 8 months of the corticoid treatment&#44; showing a reduction of the nodular lesions and no enlarged lymph nodes&#46;</p><p class="elsevierStylePara"><img alt="Figure 4 – Immunohistochemical IgG4 staining with increase of IgG4&#43; plasma cells in the inflammatory infiltrate &#40;x200&#41;" src="498v35n02-90412431fig4.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 4 &#8211; Immunohistochemical IgG4 staining with increase of IgG4&#43; plasma cells in the inflammatory infiltrate &#40;x200&#41;</span></p><p class="elsevierStylePara"><img alt="Figure 5 – Electron microscopy showing an atrophic tubule with thick basement membranes containing abundant electron-dense deposits &#40;x5&#44;000&#41;" src="498v35n02-90412431fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 5 &#8211; Electron microscopy showing an atrophic tubule with thick basement membranes containing abundant electron-dense deposits &#40;x5&#44;000&#41;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion </span></p><p class="elsevierStylePara"> Our patient was referred to the Nephrology Department due to acute renal failure&#44; while being investigated for pulmonary masses and mediastinal lymphadenopathies&#46; The clinical-pathological correlation of this case led to the diagnosis of IgG4 nephropathy&#46;</p><p class="elsevierStylePara"> IgG4-related disease &#40;IgG4-RD&#41; is a systemic autoimmune process that has only recently been recognised&#46; It usually presents as inflammatory masses in multiple locations&#46; It has a typical histological appearance&#44; which is similar in all affected organs&#44; characterised by a lymphoplasmacytic infiltrate rich in IgG4&#43; plasma cells&#44; storiform fibrosis&#44; and often&#44; but not always&#44; elevated serum IgG4&#46;<span class="elsevierStyleSup">1&#44;2</span> IgG4-RD was initially described in the pancreas&#44; but it can affect any organ&#46; The clinical manifestations vary depending on disease severity and organs affected&#46;</p><p class="elsevierStylePara"> IgG4-RD is more prevalent among males than females&#44; with a ratio of 3&#58;1&#44; and it is more frequent in patients over the age of 50&#46;</p><p class="elsevierStylePara"><img alt="Figure 6 – Thoracic CT scan&#58; bilateral pulmonary nodules with air bronchograms and irregular margins" src="498v35n02-90412431fig6.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 6 &#8211; Thoracic CT scan&#58; bilateral pulmonary nodules with air bronchograms and irregular margins</span></p><p class="elsevierStylePara"><img alt="Figure 7 – Thoracic CT scan after treatment&#58; resolving nodules in a follow-up CT scan 8 months later" src="498v35n02-90412431fig7.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 7 &#8211; Thoracic CT scan after treatment&#58; resolving nodules in a follow-up CT scan 8 months later</span></p><p class="elsevierStylePara"> In the kidney&#44; it can present as nodules or as diffuse infiltration in enlarged kidneys&#46;<span class="elsevierStyleSup">3</span> The diagnosis is reached by renal biopsy&#44; which shows tubulointerstitial nephritis &#40;TIN&#41; rich in plasma cells expressing IgG4&#44; with abundant eosinophils in some cases&#46; The presence of deposits in the tubular basement membranes is also a diagnostic criterion for this disease&#46;<span class="elsevierStyleSup">4</span> As TIN is non-specific&#44; it is easy to underdiagnose IgG4-RD unless an adequate clinical-pathological correlation is established&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara"> In the largest series of patients with IgG4-RD &#40;n&#61;153&#41;&#44; Saeki et al reported that approximately 20&#37; of cases had renal involvement confirmed by biopsy&#44;<span class="elsevierStyleSup">6</span> which often revealed an IgG4&#43; plasma cell-rich lymphoplasmatic infiltrate&#46; Moreover&#44; up to 70&#37; of the patients in this series had elevated serum IgG4 levels&#44; hypergammaglobulinaemia and hypocomplementaemia&#46;<span class="elsevierStyleSup">7</span> Furthermore&#44; some of these patients did not have autoimmune pancreatitis&#46;</p><p class="elsevierStylePara"> The IgG4 molecule only accounts for 5&#37; of the total concentration of IgG under normal conditions&#46; IgG4 has a wide range of plasma concentrations&#44; which range between 0&#46;01 and 1&#46;40 mg&#47;dL&#46; In contrast to those of other IgG subclasses&#44; the heavy chains &#40;Fc region&#41; of IgG4 are bound by weak disulphide bridges&#46; This facilitates IgG4 division and the formation of &#8220;hybrid&#8221; IgG4 molecules with 2 Fc and 2 light chains &#40;Fab&#41; with an affinity for different antigens&#46; This reduces their propensity to form immune complexes&#44; but they show a notable tendency to mimic rheumatoid factor activity&#44; binding to each other through the Fc&#46; IgG4 is produced when there is repeated and&#47;or prolonged exposure to certain antigens &#40;in infections and allergies&#41;&#46; IgG4 production is controlled by the T helper 2 cell response&#46;<span class="elsevierStyleSup">1</span> From an immunological standpoint&#44; our patient initially had very elevated IgG4 levels&#46; In addition&#44; we observed an activation of the classical complement pathway &#40;low C3 and C4&#41;&#44; in common with other cases&#44; and which seems to be related to the presence of circulating immune complexes&#46; The literature describes IgG4-related disease as an autoimmune pathology triggered by a reaction against certain autoantigens &#40;such as lactoferrin and carbonic anhydrase II&#41;&#46; The autoantibodies formed in the inflamed organs could bind to epithelial antigens&#44; leading to immune complex deposits on the epithelial basement membranes&#46; Furthermore&#44; although IgG4 does not activate the classical complement pathway by itself&#44; it seems that other isoforms present in the kidney &#40;such as IgG1 and IgG3&#41; could activate it&#46; Also&#44; it appears that IgG4 could activate the complement cascade through the lecithin pathway&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara"> In addition to its role in IgG4-RD&#44; IgG4 has also been associated with other diseases&#44; such as Mikulicz syndrome&#44; Riedel&#8217;s thyroiditis&#44; Ormond&#8217;s disease&#44; retroperitoneal fibrosis and inflammatory pseudotumours&#46; In the kidney&#44; IgG4-RD is manifested as TIN&#44; but there have also been cases of renal involvement in the form of membranous glomerulonephritis &#40;GN&#41; &#40;9&#37;&#41;&#44; IgA GN and nonspecific GN&#46;<span class="elsevierStyleSup">6&#44;9</span></p><p class="elsevierStylePara"> Clinically&#44; IgG4-RD manifests as constitutional syndrome&#44; with fever and elevated acute phase reactants&#44; as well as chance findings in radiographic images&#46; In cases involving the kidneys&#44; patients have proteinuria in a nonnephrotic range with or without renal failure&#46; Some patients have allergic symptoms &#40;asthma&#44; eczema&#44; atopy&#44; eosinophilia&#41; and up to 40&#37; of cases also present sinusitis and bronchial asthma&#46; Our patient had primary involvement of the lungs&#44; kidneys and mediastinal lymph nodes&#44; and his rapidly progressive renal failure was particularly striking in this context&#46;</p><p class="elsevierStylePara"> Given the rarity of the disease&#44; there is no scientific evidence regarding treatment&#44; but usually the recommended therapy is based on corticosteroids&#46;<span class="elsevierStyleSup">10</span> In general&#44; patients are treated when the lymphoplasmacytic infiltrates cause target organ dysfunction &#40;kidney dysfunction&#44; in our case&#44; led to renal failure&#41;&#46; Caution should be exercised when treating asymptomatic patients and those with only enlarged lymph nodes&#44; since the drugs involved have well-known adverse effects&#46; Glucocorticoids are administered at doses of 0&#46;6 mg&#47; kg&#44; and the dose is reduced progressively after 2 to 4 weeks&#44; leaving the patient with a prednisone dose of 2&#46;5-5 mg&#47;day for 3 years&#46; Azathioprine&#44; mycophenolate mofetil and methotrexate have been used as maintenance therapy with no clear scientific evidence&#46; There have also been some cases of resistant disease&#44; as well as recurrences&#44; which have been treated with rituximab&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara"> The key determinant of treatment response is usually the level of fibrosis of the affected organ&#46; IgG4 plasma levels do not return to normal values in 63&#37; of cases&#44; of which only 30&#37; present recurrences&#46; In some cases&#44; monitoring of IgG4 levels could be used to identify recurrences&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of Interest </span></p><p class="elsevierStylePara"> The authors have no conflicts of interest to declare&#46;</p><hr></hr><p class="elsevierStylePara"> Sent for review on 14<span class="elsevierStyleSup">th</span> August 2013 <br></br> Accepted on 2<span class="elsevierStyleSup">nd</span> January 2015</p><p class="elsevierStylePara"> &#42; <span class="elsevierStyleItalic">Corresponding author</span>&#46;<br></br> Loreto Fern&#225;ndez Lorente&#44; <br></br> Servicio de Nefrolog&#237;a&#44; Complejo Hospitalario de Navarra&#44; <br></br> Calle Irunlarrea&#44; 3&#44; 31008 Pamplona&#44; Navarra&#44; Spain&#46; <br></br> Tel&#46;&#58; 686174157<br></br><span class="elsevierStyleItalic">E-mails&#58; </span><a href="mailto&#58;ml&#46;fernandez&#46;lorente&#64;navarra&#46;es" class="elsevierStyleCrossRefs">ml&#46;fernandez&#46;lorente&#64;navarra&#46;es</a>&#59; <a href="mailto&#58;loretofer&#64;msn&#46;com" class="elsevierStyleCrossRefs">loretofer&#64;msn&#46;com</a></p>"
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        "resumen" => "<p class="elsevierStylePara"> El caso presentado es el de un paciente var&#243;n de 73 a&#241;os que debuta con un fracaso renal agudo en el contexto de infiltrados pulmonares y adenopat&#237;as mediast&#237;nicas a estudio&#46; En el an&#225;lisis de orina destac&#243; proteinuria de rango tubular&#44; sin microhematuria&#46; En el estudio inmunol&#243;gico se observ&#243; &#250;nicamente una elevaci&#243;n de los valores normales de IgG&#44; junto con una activaci&#243;n de la v&#237;a cl&#225;sica del complemento&#46; La biopsia renal y la correcta correlaci&#243;n cl&#237;nico-patol&#243;gica fueron definitivas en este caso&#44; mostrando una vez m&#225;s ser una herramienta fundamental en el diagn&#243;stico del fracaso renal agudo de etiolog&#237;a no clara&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> This is a case report of a 73-year-old man with new-onset acute renal failure while being investigated for pulmonary infiltrates and mediastinal lymphadenopathies&#46; Urine tests showed tubular range proteinuria with no microhaematuria&#46; Immunology tests showed elevated serum IgG and hypocomplementaemia &#40;classical pathway activation&#41;&#46; Renal biopsy and clinical-pathological correlation were crucial in this case&#44; reinforcing their important role in the final diagnosis of acute kidney injury&#46;</p>"
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