Letter to the Editor
Don’t forget syphilis in membranous nephropathy before immunosuppressants: Latent syphilis in a patient with proteinuria
No olvide la sífilis en la nefropatía membranosa antes de los inmunosupresores
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"nombre" => "Beyhan" "apellidos" => "Güvercin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Sevdegül" "apellidos" => "Mungan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Şükrü" "apellidos" => "Ulusoy" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Nephrology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "No olvide la sífilis en la nefropatía membranosa antes de los inmunosupresores" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 720 "Ancho" => 955 "Tamanyo" => 90537 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Granular Ig G deposition along glomerular basal membranes on immunofluorescence microscopy ×200.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with proteinuria especially nephrotic syndrome are more prone to infections both due to immunosuppressive drugs used in treatment and low Ig G levels because of loss through urine.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In addition, certain infections such as hepatitis B and C, human immunodefficiency virus (HIV) might be responsible for the glomerulonephritis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> So detailed medical history and certain screening tests are mandatory for discrimination of primary glomerulonephritis from secondary post-infectious forms and for protection of the patients from reactivation of silent micro-organisms with induction of immunosuppressive therapy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">37 years old male married patient with a history of panic attack and hypertension was presented with dispnea due to pleural effusion. Biochemically: serum creatinine: 0.64<span class="elsevierStyleHsp" style=""></span>mg/dL, haemoglobin: 13.2<span class="elsevierStyleHsp" style=""></span>g/dL, albumin: 2.1<span class="elsevierStyleHsp" style=""></span>g/dL, creatinine clearance: 126<span class="elsevierStyleHsp" style=""></span>mL/min, LDL-C: 315<span class="elsevierStyleHsp" style=""></span>mg/dL, 24-h urine protein excretion: 19<span class="elsevierStyleHsp" style=""></span>g/day, 24-hour urine albumin excretion: 10.7<span class="elsevierStyleHsp" style=""></span>g/day. Ultrasonographically kidneys were normal. Renal biopsy revealed membranous nephropathy stage 2 (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Our routine infection screening revealed positive results for syphilis antibodies with ELISA test (1/250 cut off index). Validation tests (Treponema palladium hemagglutination assay – TPHA – for both Ig M and Ig G) confirmed the diagnosis of asymptomatic (latent) syphilis. As there was no expressed recent history of high risk sexual behaviour, late latent syphilis was thought and three weekly doses of penicillin G benzathine (2.4 million units i.m.) were given to the patient. Serum complement levels of the patient were normal and proteinuria level of patient was not decreased with this therapy. As anti-phospholipase A2 receptor antibody (PLA2Rab) was positive (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>20 RU/mL) with ELISA test (result: 164<span class="elsevierStyleHsp" style=""></span>RU/mL), diagnosis of primary membranous glomerulopathy was ascertained. Under treatment of steroid and cyclosporine, his serum albumin levels increased to 3.1<span class="elsevierStyleHsp" style=""></span>g/dL, and proteinuria decreased to 1<span class="elsevierStyleHsp" style=""></span>g/day within one month.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Most of the membranous glomerulopathy (nearly 75%) cases are known as idiopathic (primary) without any identifiable causes such as infections, drugs, auto-immune diseases, neoplasms.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Serological tests (PLA2Rab, hepatitis B, C, HIV and syphilis) are important for both differential diagnosis of membranous glomerulopathy and minimize side effects of immunosuppressive treatment.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> KDIGO guidelines do not advice to screen for syphilis routinely in patients with primary membranous glomerulopathy.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In addition, literature review showed many cases of syphilis as a cause of membranous glomerulopathy but as far as we know no report with latent syphilis along with primary membranous glomerulopathy was published. Also, one should remember false positive syphilis results (due to cross reactions with other antibodies) if one of nontreponemal tests (VDRL, RPR) is reactive and other one of treponemal tests (ELISA, TPHA, FTA-ABS) is nonreactive. In order to diagnose the organism directly PCR or direct fluorescent antibody testing for treponema palladium are used.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Presence of positive serology for syphilis (two different types of treponemal tests for antibodies against syphilis including Ig M and Ig G), absence of any sign of infection and treatment history is defined as -presumed- latent syphilis as in our case.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Anti-PLA2Rab is very specific for diagnosis and monitoring immunological activity of primary membranous glomerulopathy.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> In our patient, with the presence of anti-PLA2Rab and absence of remission in proteinuria after 3 weeks of optimum treatment against syphilis, primary membranous glomerulopathy related nephrotic syndrome was diagnosed. In this particular patient, if the screening for syphilis had not been done, immunosuppressive treatment for primary membranous glomerulopathy might have led to progression through advanced (tertiary) syphilis infection.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> This case makes us think it should be better to screen for syphilis before onset of immunosuppressive treatment even among patients with primary membranous glomerulopathy.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authorship contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Concept: Kubra Kaynar; Design: Kubra Kaynar, Beyhan Guvercin; Control: Sukru Ulusoy; Data Collection: Sevdegul Mungan; Literature review: Kubra Kaynar; Writing the manuscript: Kubra Kaynar, Beyhan Guvercin.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Compliance with ethical standards</span><p id="par0030" class="elsevierStylePara elsevierViewall">No conflict of interests was declared. No fund was taken. Informed consent was obtained from the patient.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authorship contributions" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Compliance with ethical standards" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "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" => 720 "Ancho" => 955 "Tamanyo" => 198650 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy which display glomeruli with basal membrane thickening and enhanced mesangial matrix H.E. ×200.</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" => 720 "Ancho" => 955 "Tamanyo" => 90537 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Granular Ig G deposition along glomerular basal membranes on immunofluorescence microscopy ×200.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Serum immunoglobulins in the nephrotic syndrome. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 12 | 11 | 23 |
| 2024 Octubre | 46 | 37 | 83 |
| 2024 Septiembre | 53 | 30 | 83 |
| 2024 Agosto | 72 | 72 | 144 |
| 2024 Julio | 74 | 17 | 91 |
| 2024 Junio | 67 | 34 | 101 |
| 2024 Mayo | 86 | 45 | 131 |
| 2024 Abril | 63 | 35 | 98 |
| 2024 Marzo | 51 | 37 | 88 |
| 2024 Febrero | 59 | 38 | 97 |
| 2024 Enero | 56 | 29 | 85 |
| 2023 Diciembre | 50 | 26 | 76 |
| 2023 Noviembre | 61 | 39 | 100 |
| 2023 Octubre | 50 | 33 | 83 |
| 2023 Septiembre | 55 | 29 | 84 |
| 2023 Agosto | 43 | 28 | 71 |
| 2023 Julio | 47 | 27 | 74 |
| 2023 Junio | 71 | 24 | 95 |
| 2023 Mayo | 90 | 43 | 133 |
| 2023 Abril | 57 | 22 | 79 |
| 2023 Marzo | 53 | 29 | 82 |
| 2023 Febrero | 33 | 34 | 67 |
| 2023 Enero | 41 | 34 | 75 |
| 2022 Diciembre | 96 | 40 | 136 |
| 2022 Noviembre | 49 | 31 | 80 |
| 2022 Octubre | 52 | 42 | 94 |
| 2022 Septiembre | 40 | 44 | 84 |
| 2022 Agosto | 55 | 51 | 106 |
| 2022 Julio | 53 | 49 | 102 |
| 2022 Junio | 30 | 47 | 77 |
| 2022 Mayo | 56 | 34 | 90 |
| 2022 Abril | 48 | 55 | 103 |
| 2022 Marzo | 57 | 51 | 108 |
| 2022 Febrero | 68 | 53 | 121 |
| 2022 Enero | 43 | 37 | 80 |
| 2021 Diciembre | 79 | 42 | 121 |
| 2021 Noviembre | 67 | 44 | 111 |
| 2021 Octubre | 40 | 60 | 100 |
| 2021 Septiembre | 31 | 34 | 65 |
| 2021 Agosto | 28 | 43 | 71 |
| 2021 Julio | 33 | 37 | 70 |
| 2021 Junio | 29 | 26 | 55 |
| 2021 Mayo | 46 | 45 | 91 |
| 2021 Abril | 113 | 105 | 218 |
| 2021 Marzo | 71 | 37 | 108 |
| 2021 Febrero | 35 | 37 | 72 |
| 2021 Enero | 47 | 36 | 83 |
| 2020 Diciembre | 76 | 45 | 121 |
| 2020 Noviembre | 24 | 23 | 47 |
| 2020 Octubre | 19 | 25 | 44 |
| 2020 Septiembre | 19 | 23 | 42 |
| 2020 Agosto | 24 | 23 | 47 |
| 2020 Julio | 19 | 20 | 39 |
| 2020 Junio | 28 | 29 | 57 |
| 2020 Mayo | 36 | 19 | 55 |
| 2020 Abril | 38 | 26 | 64 |
| 2020 Marzo | 90 | 33 | 123 |
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