Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
Journal website http://www.jocmr.org

Case Report

Volume 7, Number 7, July 2015, pages 575-581


An Overlapping Case of Lupus Nephritis and IgG4-Related Kidney Disease

Figures

Figure 1.
Figure 1. Light microscopy (A, B) shows: (A) mildly thickened glomerular basement membrane and (B) diffuse acute tubular injury with epithelial simplification consistent with acute tubular necrosis (ATN). Immunoperoxidase staining (C, D): immunostaining for IgG4 shows IgG4 positive plasma cells in the interstitium.
Figure 2.
Figure 2. Immunofluorescence (IF) showing (A) granular glomerular capillary wall staining 2+ for IgG and (B) granular diffuse tubular basement membranes staining 2+ for IgG.

Tables

Table 1. Evolution of BUN and Creatinine Over Days
 
DayAdmissionDay 2Day 3Day 4Day 5Day 6
BUN (mg/dL)881001001058240
Creatinine (mg/dL)9.659.279.209.709.05.80

 

Table 2. Laboratory Findings
 
ParameterValue
Creatinine (mg/dL)9.65
BUN (mg/dL)88
Total protein (g/dL)6.10
Albumin (g/dL)2
Thyroid stimulating hormone (TSH) (µIU/mL)0.81
Hepatitis B surface antigen (HbsAg)Reactive
IgM hepatitis B core antibodyNon-reactive
Hepatitis B viral DNA (copies)22576
Urinary protein (g/day)2.60
ESR (mm/h)61
Antinuclear antibody (ANA)1:320, homogeneous
Antineutrophil cytoplasmic antibody (ANCA)Negative
Complement C3 (mg/dL)100 (reference range 80 - 180)
Complement C4 (mg/dL)11 (reference range 10 - 45)
Anti-SSA antibodyNegative
Anti-SSB antibodyNegative
Anti-RNP antibodyNegative
Anti-dsDNA antibodyNegative
Smith antibody (anti-Sm)Negative
IgG1 (mg/dL)1230 (reference range 382 - 929)
IgG2 (mg/dL)735 (reference range 241 - 700)
IgG3 (mg/dL)418 (reference range 22 - 178)
IgG4 (mg/dL)37.10 (reference range 4 - 86)
Serum protein electrophoresis (SPEP)Normal
Glomerular basement membrane antibody (anti-GBM)Negative
CryoglobulinNegative

 

Table 3. Immunofluorescence Results
 
GlomeruliTubulesInterstitiumVessels
Immunofluorescence results showing granular global mesangial and irregular capillary wall, as well as abundant tubular basement membrane granular deposits staining for a “full-house” of immune reactants (deposits containing IgM, IgA, IgG, Kappa, Lamda, C3 and C1). gloms: glomeruli; Gran: granular; mes: mesangial; GCW: glomerular capillary wall; TBM: tubular basement membrane; Neg: negative; FBGN: fibrinogen; ALB: albumin.
IgG3 gloms 2+
Gran global mes
Gran diffuse
TBM’s 2+
Sparse GCW
NegNeg
IgM3 gloms 1+
Gran global mes
Sparse GCW
TBM’s 1+
Gran focal
Plasma cells +1
cytoplasm
Neg
IgA3 gloms 1+
Gran global mes
Sparse GCW
TBM’s 1+
Gran focal
Plasma cells +1
cytoplasm
Neg
C33 gloms 1+
Gran global mes
Sparse GCW
TBM’s 1+
Gran diffuse
NegNeg
C13 gloms negTBM’s 1+
Gran focal
NegNeg
FBGN3 gloms negNeg2+Neg
ALB3 gloms negNegNegNeg
KAPPA3 gloms 2+
Gran global mes
Sparse GCW
TBM’s 2+
Gran diffuse
Plasma cells
+1
cytoplasm
Neg
LAMDA3 gloms 2+
Gran global mes
Sparse GCW
TBM’s 2+
Gran diffuse
Plasma cells +1
cytoplasm
Neg