Secondary amyloidosis associated with tuberculosis in renal biopsy

Abstract

Secondary amyloidosis associated with tuberculosis in renal biopsyAmiloidose secundária associada à tuberculose numa biópsia renal A 46-year-old woman with a history of diabetes, drug addiction, hepatitis C virus (HCV), and human immunodeficiency virus (HIV) was presented to our department with a 4-month history of edema, fever, and cough. Chest radiography showed an opacification in the upper lobe of the left lung, but laboratory tests were negative for tuberculosis (TB). Nevertheless, the treatment for pulmonary TB was started. Serum creatinine and albumin levels were 0.8mg/dL and 2.5g/dL, respectively. The urinary protein excretion was 7.5g/24h. A renal biopsy performed six weeks after beginning the TB treatment showed a mild mesangial expansion of amorphous and acellular pale eosinophilic material. The material had affinity for Congo red stain ( Figure A) that was lost after exposure to KMnO4. The interstitial area shows foci of mixed inflammatory cell infiltrate and epithelioid granulomas with Langhans giant cells and central necrosis (Figure B). Probably due to treatment, Ziehl-Neelsen stains were negative. The final diagnosis was secondary amyloidosis and granulomatous interstitial nephritis compatible with tuberculosis. Two years later, the albumin level was 4.2g/24h, serum creatinine was 1.0mg/dL, proteinuria decreased to 1.2g/24h, and all symptoms disappeared.We report this case to emphasize the importance of renal biopsy in patients with infectious diseases (HCV, HIV, TB) and nephropathy. In addition, this is the first case in which a renal biopsy showed the concomitant diagnosis of TB granulomas and AA amyloidosis deposits.Uma paciente de 46 anos, com história de diabetes mellitus, uso de drogas, vírus da hepatite C (VHC) e vírus da imunodeficiência humana (HIV) foi admitida em nosso serviço queixando-se de edema, febre e tosse. A radiografia de tórax mostrou uma opacificação no lobo superior do pulmão esquerdo, mas os testes laboratoriais foram negativos para tuberculose pulmonar (TB). Apesar disso, ela foi tratada para TB. Os níveis de creatinina e albumina eram de 0,8mg/dL and 2,5g/dL respectivamente. A proteinúria era de 7,5g/24h. Uma biópsia renal realizada seis semanas após o inicio de tratamento para TB mostrou leve expansão mesangial a custas de material amorfo e fracamente eosinofílico. O material tinha afinidade pelo vermelho Congo (Figura A), que era perdida na exposição ao KMnO4. No interstício, havia um infiltrado inflamatório granulomatoso com células gigantes de Langhans e necrose central (Figura B). A pesquisa de bacilo (ZiehlNeelsen) foi negativa muito provavelmente pelo tratamento instituído. O diagnóstico final foi de amiloidose secundária devido a uma nefrite intersticial granulomatosa por TB. Dois anos após o tratamento, a albumina estava em 4,2g/24h, a creatinina em 1,0mg/dL, a proteinúria caiu para 1,2g/24h, e todos os sintomas haviam desaparecidos.Destacamos aqui a importância da biópsia renal nos pacientes com doenças infecciosas (HCV, HIV e TB) e nefropatia. Além do mais, es...

Pattern of renal amyloidosis in South Africa

“…HIV infection has been associated with both AA and AL amyloidosis in case reports [21, 22, 26–28]. Most cases of AA amyloidosis have been reported in IVDUs, fewer cases with visceral leishmaniasis and multicentric Castleman’s disease, and to our knowledge, only 1 case report exists of HIV, amyloidosis and presumed TB coexisting in a known IVDU [20–22, 29, 30].…”

“…Gerntholz et al [16] identified no cases of amyloidosis among 99 patients and Wearne and Okpechi [17] a single one among 221 South African patients; Wyatt et al [18] reported one case of amyloidosis among 89 American and as did Nebuloni et al [19] in 73 Italian subjects. The cases of amyloidosis and HIV infection that have been reported are predominantly in intravenous drug users (IVDUs) [20–22]. Data from the pre-HIV era in South Africa suggest that AA amyloidosis is the most common type of amyloidosis seen and that TB infection is the most frequently associated risk factor [2].…”

Incidence of Tuberculosis and Amyloidosis among Sudanese Patients Presented with Enlarged Nodes

“…To the best of our knowledge, this is the first report about amyloidosis from Sudan. However, the relationship between amyloidosis and tuberculosis was well established [ 26 , 27 ]. Amyloidosis (AA) can occur secondary to several infectious, inflammatory, and malignant conditions and is caused by the degradation of the acute-phase protein that is produced in response to inflammatory conditions [ 28 , 29 ].…”

Best practice in the diagnosis and management of urogenital tuberculosis

“…It is necessary to keep in mind that biopsy for confirming UGTB by histology may have serious complications [Kulchavenya, 2010;Silva et al 2011] until generalization of TB in untreated patient. Miliary TB has been diagnosed in a patient resulting from the hematogenous spread following transurethral ultrasound (TRUS)-guided prostate biopsy [Kim et al 2011].…”

“…It is necessary to keep in mind that biopsy for confirming UGTB by histology may have serious complications [Kulchavenya, 2010; Silva et al . 2011] until generalization of TB in untreated patient.…”