Tubulointerstitial nephritis and uveitis syndrome following meningitis and systemic lymphadenopathy with persistent Toxoplasma immunoglobulin M: a case report

Abstract

Background Tubulointerstitial nephritis and uveitis syndrome is a rare lymphocyte-related oculorenal inflammatory disease presumed to be associated with drug use and infectious agents. Toxoplasma gondii is one of such pathogens that could exhibit encephalitis, meningitis, and uveitis in immunocompromised or in some immunocompetent individuals. If the immunoglobulin M of Toxoplasma is positive on screening, the interpretation of the result is not simple, especially when immunoglobulin M stays positive persistently. Case presentation A 34-year-old Asian male developed fever, headache, and lymphadenopathy with tenderness, which was initially diagnosed as meningitis. Antibiotics were started, and diclofenac sodium was used for the fever. Although his symptoms were alleviated in a week by the treatment, gradual decline in renal function was noted, prompting a renal biopsy that indicated acute granulomatous interstitial nephritis. A week later, tenderness in both eyes with blurred vision appeared and revealed iritis and keratic precipitations in both eyes; hence, the diagnosis of acute tubulointerstitial nephritis and bilateral uveitis syndrome was made. Toxoplasma gondii-specific immunoglobulin G and immunoglobulin M titers were both positive. Although we could not rule out recent infection of Toxoplasma gondii, which may cause uveitis initially, Toxoplasma immunoglobulin G avidity test indicated a distant infection, which allowed us to rule out meningitis and uveitis as responsible for the complication of recent Toxoplasma gondii infection. Drug-induced lymphocyte stimulation test, or lymphocyte transformation test of diclofenac sodium, was solely positive among the tested drugs. Uveitis was alleviated only with ophthalmic steroid, and renal function returned to normal without administration of systemic steroid. Conclusions We experienced a case of diclofenac-induced tubulointerstitial nephritis and uveitis syndrome. In ruling out infections, Toxoplasma immunoglobulin M was persistently positive, and Toxoplasma immunoglobulin G avidity test indicated a “distant” infection. From these two results, we ruled out recent infection. However, it should be noted that “distant” infection indicated by commercial immunoglobulin G avidity is still a multiplex profile consisting of reinfection, reactivation, and latent infection. Narrowing down the infection profile of Toxoplasma is challenging in some cases. Therefore, careful diagnosis and extended follow-up of such patients are needed.

Antibodies against Toxoplasma gondii positive in serum and aqueous humor to diagnose clinically suspected ocular toxoplasmosis: A case report

“…However, it should be noted that Toxoplasma antibody positive is still a multiplex profile consisting of reinfection, reactivation, and latent infection. [ 5 ] Determine the infection profile of toxoplasma might pose a diagnostic challenge in some cases. Therefore, careful diagnosis considering both ophthalmic examinations and serology of such patients are needed.…”

Management of corticosteroid-dependent eosinophilic interstitial nephritis

“…[ 8 ] Unfortunately, there are no definitive ways to select one or more offending drugs from many other drugs in patients with DI-AIN. Although the LST, an in vitro test for type IV allergic reactions, has been utilized to determine the offending drug(s) in patients with DI-AIN, it has an inadequate diagnostic sensitivity, [ 9 ] and is therefore not widely recommended. Indeed, the patient in the present case experienced repeated AIN recurrence even after zoniamide discontinuation (as indicated by the positive LST result), suggesting that it was not the offending drug.…”