Treatment challenges in an atypical presentation of tubulointerstitial nephritis and uveitis (TINU)

Abstract

PurposeTo describe an atypical presentation of Tubulointerstitial Nephritis and Uveitis (TINU), with challenges in treatment course.ObservationsA 12-year-old Hispanic female presented to the National Eye Institute's Uveitis clinic with bilateral blurred vision, red eyes and photophobia, not responsive to topical steroids. On exam, she had bilateral severe panuveitis with areas of subretinal fluid. During her evaluation, she was noted to have elevated serum creatinine. A kidney biopsy confirmed the presence of severe tubulointerstitial nephritis and interstitial fibrosis. She was treated with oral steroids with excellent resolution of symptoms and subretinal fluid. She continued to have anterior segment flares with attempts to taper oral prednisone which lead to treatment with multiple immunomodulatory agents. Associated hypertension and kidney damage complicated the choice of a secondary immunosuppressive agent.Conclusions and ImportanceAlthough rare, TINU can present as panuveitis with choroidal involvement which may or may not be preceded by tubulointerstitial nephritis. A renal biopsy is required for definitive diagnosis, but abnormal urinalysis or renal function should raise suspicion for TINU.

Acute Kidney Injury Relevant to Tubulointerstitial Nephritis with Late-Onset Uveitis Superimposed by Thrombotic Microangiopathy: A Case Report and Review of the Literature

“…There have been no evidence-based protocols for treating patients with TINU syndrome [52]. Case reports have suggested alternate immunosuppressive therapies, such as CTX [53], azathioprine [54], mycophenolate mofetil [55], and cyclosporine A [56], on the basis of steroid therapy. However, how long immunosuppressive therapy should be extended (especially in patients with recurrent kidney injury), whether additional immuno-DOI: 10.1159/000507668 suppressive medications should be added, and what combination of medications is preferred need further studies to be determined.…”

A case of tubulointerstitial nephritis and uveitis syndrome accompanied by subclinical choroiditis

“…Most cases present only anterior uveitis [1], and some present posterior segment ndings, including redness and/or swelling of the optic disc, snowball vitreous opacity, and retinal exudates [2]. However, a few cases of TINU accompanied by choroiditis have been reported [3,4]. We report a case of TINU syndrome in which the presence of choroiditis was revealed by multimodal imaging.…”

Multimodal imaging in pediatric uveitis

“… 77 – 79 While most present with mild anterior uveitis, panuveitis, intermediate, 79 and posterior uveitis 77 have also been reported, and are typically responsive to corticosteroids. 77 , 79 , 80 Diagnosis and prompt treatment with corticosteroids is necessary to prevent complications, which may include posterior synechiae, chorioretinal lesions ( Figure 5 ), rhegmatogenous retinal detachment, and choroidal neovascularization. 77 – 79 If corticosteroid treatment is ineffective or unable to be tapered to a safe level, immunomodulators can be considered.…”

“… 77 – 79 If corticosteroid treatment is ineffective or unable to be tapered to a safe level, immunomodulators can be considered. 80 …”