Tubulointerstitial Nephritis and Uveitis Syndrome with non Caseating Granuloma in Bone Marrow Biopsy

Abstract

RESUMOA Síndrome nefrite túbulo intersticial e uveíte é uma síndrome rara e provavelmente sub-diagnosticado na prática clinica. É caracterizada pela ocorrência de nefrite intersticial e de uveíte, sendo um diagnóstico de exclusão. Granulomas não caseosos nos vários tecidos são raros, estando descritos apenas seis casos de granulomas não caseosos na medula óssea. Apresentamos um caso de uma mulher de 55 anos, com quadro de três meses de evolução de astenia e emagrecimento. Laboratorialmente apresentava anemia e insuficiência renal. A biopsia renal revelou nefrite intersticial e a biópsia da medula óssea mostrou granulomas não caseosos. Um mês depois surgiu uveíte anterior do olho esquerdo. A exclusão de todas as possíveis etiologias permitiu o diagnóstico final de Síndrome nefrite túbulo intersticial e uveíte com granulomas não caseosos na medula óssea. Considerando que as manifestações oculares e renais podem não ocorrer simultaneamente, a Síndrome nefrite túbulo intersticial e uveíte deve ser sistematicamente equacionada em doentes com nefrite intersticial e/ou uveíte, podendo os granulomas fazer parte desta rara patologia. Palavras-chave: Granuloma; Medula Óssea; Nefrite Intersticial; Uveíte. ABSTRACTThe Tubulointerstitial Nephritis and Uveitis syndrome is a very rare condition, probably under-diagnosed in clinical practice. It is characterized by the combination of an interstitial nephritis and uveitis, and is an exclusion diagnosis. Tissue non caseating granuloma can be rarely present, with only 6 cases reported on bone marrow. We present a case of a 55 year old female with a 3-month history of asthenia and weight loss. Blood tests showed anemia and renal insufficiency. Renal biopsy revealed interstitial nephritis and the bone marrow biopsy showed caseating granuloma. One month later anterior uveitis of the left eye appeared. An extensive exclusion of all possible causes allowed a diagnosis of Tubulointerstitial Nephritis and Uveitis syndrome with caseating granuloma in bone marrow. As ocular and renal manifestations may not occur simultaneously, Tubulointerstitial Nephritis and Uveitis Syndrome should be systematically considered in cases of interstitial nephritis and/or uveitis, and tissue granulomas can be part of this rare syndrome.

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

“…TINU may be difficult to be differentiated from sarcoidosis because it is not unusual for sarcoid patients to present with uveitis and interstitial kidney diseases. Moreover, in many reported cases of TINU, the kidneys [18][19][20], liver [21], and bone marrow [19,22,23] have demonstrated sarcoid-like noncaseating granulomas. In these cases, the diagnosis of TINU was favored over that of sarcoidosis due to the absence of pulmonary involvement or increased angiotensin-converting enzyme inhibitor activity or increased urinary beta-2 microglobulin (B2M).…”

An Adolescent Girl with Tubulointerstitial Nephritis and Uveitis (TINU) Syndrome

“…Our patient's diagnosis of uveitis approximately three months after the renal disease is within the normal range of presentation, which has been reported to range from 2 months to 14 months after the onset of renal disease [1]. Diagnosis of TINU syndrome is made based on the combination of acute tubulointerstitial nephritis and uveitis and after exclusion of other potential causes, most notably systemic disease and infection [9]. Fortunately, TINU syndrome typically has a favorable prognosis [10].…”

A pediatric case of tubulointerstitial nephritis and uveitis syndrome

“…Clinically, TIN may present concurrently (15%), follow (20%) or precede (65%) uveitis (2)(3)(4)6,8,12). Renal involvement may be of acute or subacute onset, often presenting with Brazilian Journal of Health Review, Curitiba, v. 7, n. 1, p. 1923-1930, jan./fev., 2024 fever, weight loss, fatigue, malaise, anorexia, abdominal or flank pain, nausea, vomiting and oliguria (4,10).…”

“…Ocular involvement in TINU syndrome seems to be very uniform (9). Most frequently the uveitis is of sudden onset, bilateral and anterior, presenting with eye redness, decreased vision, pain and photophobia (3,6,(9)(10)(11)(12). To a lesser extent, posterior and panuveitis, have been reported (3,8,9,11,13).…”