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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">Anti-glomerular basement membrane &#40;GBM&#41; antibodies are sometimes detected in patients with sera that contain antineutrophil cytoplasmic antibodies &#40;ANCAs&#41;&#44; especially in those with specificity for myeloperoxidase &#40;MPO&#41;<span class="elsevierStyleSup">1-5</span>&#46; Double positive patients may have a clinical course and response to treatment more typical of vasculitis than of anti-GBM disease&#44; and renal function recovery may be more likely if ANCAs are present<span class="elsevierStyleSup">1</span>&#46; Recent observations<span class="elsevierStyleSup">3-5</span> however&#44; have failed to detect the differences described in early reports&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Here&#44; we present a case of a 62 years-old Caucasian female with rhinosinusitis and asthma diagnosed 2 years before was admitted at our Department with renal failure requiring dialysis&#46; She had anorexia&#44; weight loss &#40;15&#37; of body weight&#41;&#44; and weakness over the last 7 months&#46; One month before the hospitalization she developed fever&#44; persistent cough&#44; dyspnea&#44; myalgias&#44; arthralgias&#44; numbness and <span class="elsevierStyleItalic">weakness of lower limbs</span>&#46; Physical examination revealed pale skin&#44; blood pressure of 135&#47;78 mmHg&#44; heart rate of 68 beats per minute&#44; respiratory rate of 18 cycles per minute&#44; body temperature of 36&#46;3 &#176;C&#44; oliguria &#40;350 ml&#47;day&#41;&#46; Cardiac&#44; pulmonary and abdominal examination did not reveal any changes&#46; There was no ocular inflammation&#44; joint tenderness or effusion&#44; and rash&#46; Neither edema nor <span class="elsevierStyleItalic">tenderness</span> of lower limbs&#44; nor peripheral lymphadenopathies was present&#46; Neurologic examination disclosed asymmetrical motor and sensory compromise of lower limbs&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Laboratory disclosed microcytic hypochromic anemia &#40;hemoglobin&#44; 4&#46;8 g&#47;dl&#59; mean globular volume&#44; 76&#46;9 fl&#59; mean globular hemoglobin&#44; 24&#46;1 pg&#41;&#44; leucocytosis &#40;14&#46;460&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; eosinophilia &#40;2&#46;300&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; thrombocytosis &#40;880&#46;000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; elevation of erythrocyte sedimentation rate &#40;142 mm&#47;hour&#41; and of C-reactive protein &#40;20 mg&#47;dl&#41;&#44; renal failure &#40;uremia&#44; 199 mg&#47;dl&#59; creatinemia&#44; 6&#46;1 mg&#47;dl&#41;&#44; and hiperkalemia &#40;8&#46;2 mEq&#47;l&#41;&#46;&#160;Urinalysis showed proteinuria of 100 mg&#47;dl and 200 erythrocytes&#47;microliter&#46; Serum protein electrophoresis revealed IgG&#47;K monoclonal gammopathy&#46; Hepatic function tests&#44; lactate dehydrogenase&#44; calcemia&#44; and phosphatemia were on the normal range&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Renal ultrasound revealed normal sized kidneys&#44; cortical hyperechogenicity&#44; normal parenquimatous differentiation&#44; and no hydronephrosis&#46; Computed tomography &#40;CT&#41; of the face disclosed mucous thickening of the frontal&#44; ethmoid&#44; sphenoid and maxillary sinuses lining&#44; and CT of the chest revealed ground-glass opacities widely spread across both lungs&#46; Lower limbs electromiogram revealed severe multiple mononeuritis&#46; Bone marrow biopsy disclosed eosinophilic hypercellularity and no morphologic abnormalities&#46; A renal biopsy was performed and showed CGN with linear deposition of IgG along the glomerular capillaries &#40;Figure 1 and figure 2&#41;&#46; Serology for lupus &#40;antinuclear&#44; anti-double strand deoxyribonucleic acid&#44; anti-Smith&#44; extractable nuclear and anti-ribonucleoprotein antibodies&#41; was negative&#46; Serum C3&#44; and C4 were on the normal range&#46; Serology for human immunodeficiency virus types 1 and 2&#44; hepatitis B&#44; hepatitis C was also negative&#46; Indirect immunofluorescence assay detected perinuclear ANCA &#40;p-ANCA&#41; &#40;90 U&#47;ml&#41; and enzyme-linked immunosorbent assay &#40;ELISA&#41; revealed MPO specificity&#46; Anti-GBM antibodies in serum &#40;169 U&#47;ml&#41; were detected by direct ELISA&#46; According to these&#44; the diagnosis of CGN with double-positivity for anti-GBM antibodies and MPO-ANCA was established&#46; She underwent intermittent hemodialysis&#44; and immunosupressive therapy with metilprednisolone &#40;15 mg&#47;kg&#47;day&#44; 3 days&#44; IV&#41; followed by oral prednisone &#40;1 mg&#47;kg&#47;day&#41;&#44; cyclophosphamide &#40;750 mg&#47;m<span class="elsevierStyleSup">2</span>&#44; monthly&#44; IV&#41;&#44; and plasma exchange with daily exchange of one volume of plasma for 5&#37; human albumin for 14 days was initiated&#46; She also received red blood cell transfusions&#46; Two weeks later&#44; the patient was asymptomatic&#44; recovered diuresis&#44; and improved renal function&#46; At hospital discharge &#40;day 38&#41;&#44; uremia and creatinemia were 148 mg&#47;dl and 2&#46;5 mg&#47;dl&#44; respectively&#44; and hemoglobin was 10&#46;9 g&#47;dl&#46; She had no clinical or laboratorial evidence of disease relapse&#44; and she remains out of dialysis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">This case illustrates several interesting points&#46; The patient presented with symptoms and signs in other organs suggesting systemic vasculitis&#46; Serologic tests revealed coexistence of anti-GBM antibodies and MPO-ANCA&#44; and histology showed CGN with linear deposition of IgG along the glomerular capillaries&#46;&#160; Although the patient presented with renal failure requiring dialysis&#44; there was renal function recovery after immunosupression with plasma exchange&#44; without evidence of disease relapse&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In a substantial proportion of patients with CGN double-positivity for anti-GBM antibodies and ANCAs &#40;mostly MPO-ANCA&#41; is detected<span class="elsevierStyleSup">1-5</span>&#46; Double-positive patients may have a clinical course and response to treatment more typical of vasculitis than of anti-GBM disease&#44; and have possibly developed anti-GBM antibodies secondary to vasculitic glomerular damage&#46; Some patients have symptoms and signs in other organs suggesting systemic vasculitis&#44; and renal function recovery may be more likely if ANCAs are present<span class="elsevierStyleSup">1</span>&#46; Recent observations<span class="elsevierStyleSup">3-5</span> however&#44; have failed to detect the differences described earlier&#46; Rutgers et al&#46;<span class="elsevierStyleSup">4</span> reviewed 46 MPO-ANCA-positive&#44; 10 double-positive and 13 anti-GBM-positive patients with CGN&#46; Creatinemia was lower in ANCA-positive patients compared to double-positive or anti-GBM-positive patients &#40;5&#46;0&#44; 10&#46;3&#44; 9&#46;6 mg&#47;dl&#44; respectively&#59; <span class="elsevierStyleItalic">P</span> &#61; 0&#46;01&#41;&#44; and renal survival was different among the 3 groups &#40;65&#37;&#44; 10&#37;&#44; and 15&#37; of dialysis at 1 year&#44; respectively&#59; <span class="elsevierStyleItalic">P</span> &#61; 0&#46;04&#41;&#46; Levy et al&#46;<span class="elsevierStyleSup">3</span> analyzed 27 patients with CGN and double-positivity for anti-GBM antibodies and ANCAs &#40;mostly MPO-ANCA&#41;&#44; and described patient and renal survival rates of 52&#37; and 26&#37;&#44; respectively&#44; at one year&#46; Sixty-eight percent of patients were dialysis-dependent at presentation&#44; and none of these recovered renal function&#44; despite immunosuppression with or without plasma exchange&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Although patients with CGN and double-positivity for anti-GBM antibodies and ANCAs may have a poor prognosis when presenting with severe disease&#44; behaving more like anti-GBM disease than vasculitis&#44; and recovery from severe renal failure may be rare&#44; this case highlights that immunosupressive therapy with plasma exchange can improve patient and renal outcome in such patients&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><a href="grande&#47;10563&#95;108&#95;7732&#95;en&#95;10563&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10563_108_7732_en_10563_f1.jpg" alt="Kidney biopsy showing crescentic glomerulonephritis &#40;Masson trichrome&#44; x100&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Kidney biopsy showing crescentic glomerulonephritis &#40;Masson trichrome&#44; x100&#41;&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10563&#95;108&#95;7733&#95;en&#95;10563&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10563_108_7733_en_10563_f2.jpg" alt="Immunofluorescence microscopy showing linear deposition of IgG along the glomerular capillaries &#40;x400&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Immunofluorescence microscopy showing linear deposition of IgG along the glomerular capillaries &#40;x400&#41;&#46;</p>"
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