J Korean Med Sci.  2007 Dec;22(6):1074-1078. 10.3346/jkms.2007.22.6.1074.

A Case of Post-Streptococcal Glomerulonephritis with Diffuse Alveolar Hemorrhage

Affiliations
  • 1Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea. kbsnep@yahoo.co.kr

Abstract

Acute post-streptococcal glomerulonephritis (PSGN) is characterized by an abrupt onset of edema, hypertension, and hematuria. Life-threatening diffuse alveolar hemorrhage (DAH) is rarely associated with acute PSGN. There have been only two reported cases worldwide, and no case has been reported previously in Korea. Here, we present a patient who clinically presented with pulmonary-renal syndrome; the renal histology revealed post-infectious glomerulonephritis of immune complex origin. A 59-yr-old woman was admitted with oliguria and hemoptysis two weeks after pharyngitis. Renal insufficiency rapidly progressed, and respiratory distress developed. Chest radiography showed acute progressive bilateral pulmonary infiltrates. The clinical presentation suggested DAH with PSGN. Three days after treatment with high-dose steroids, the respiratory distress and pulmonary infiltrates resolved. Electron microscopy of a renal biopsy specimen sample revealed diffuse proliferative glomerulonephritis with characteristic subendothelial deposits of immune complex ("hump''). The renal function of the patient was restored, and the serum creatinine level was normalized after treatment.

Keyword

Post-Streptococcal Glomerulonephritis; Diffuse Alveolar Hemorrhage

MeSH Terms

Biopsy
Female
Glomerulonephritis/*etiology
Hemorrhage/*etiology
Humans
Kidney/pathology
Lung Diseases/etiology
Middle Aged
*Pulmonary Alveoli
Streptococcal Infections/*complications

Figure

  • Fig. 1 Chest radiography on admission showed bilateral pulmonary infiltrates with blunting of both costophrenic angles (A), and chest radiography on the fourth hospital day showed that the pulmonary edema and infiltration were progressing (B). The chest abnormalities resolved after three days of steroid treatment (C).

  • Fig. 2 The CT revealed bilateral pleural effusion and alveolar consolidation or alveolar hemorrhage at both middle and lower lung fields.

  • Fig. 3 The lung biopsy on light microscopy showed eosinophils, neutrophils, and nuclear dust deposition in the alveolar interstitium, septal thickening, and fibrin clots attached to the interalveolar septa (A, H&E ×200; B, H&E ×400).

  • Fig. 4 The renal biopsy specimen on light microscopy showed proliferative glomerulonephritis with neutrophils in the masangium (A, H&E ×200, B, H&E ×400; C, H&E ×400). Electron microscopy showed mesangial hypercellularity with neutrophils and subendothelial electron-dense deposits (D, E).


Cited by  1 articles

Comment on: A Case of Post-streptococcal Glomerulonephritis with Diffuse Alveolar Hemorrhage
Jae Il Shin, Jae Seung Lee
J Korean Med Sci. 2008;23(2):355-355.    doi: 10.3346/jkms.2008.23.2.355.


Reference

1. Lombard CM, Colby TV, Elliott CG. Surgical pathology of the lung in anti-basement membrane antibody-associated Goodpasture's syndrome. Hum Pathol. 1989. 20:445–451.
Article
2. Kim YO, Choi JY, Park JI, Yoon SA, Yang CW, Hyoung K, Bang BK. A case of Goodpasture's syndrome with massive pulmonary hemorrhage. J Korean Med Sci. 2000. 15:99–102.
Article
3. Gallagher H, Kwan JT, Jayne DR. Pulmonary renal syndrome: a 4-year, single-center experience. Am J Kidney Dis. 2002. 39:42–47.
Article
4. Zamora MR, Warner ML, Tuder R, Schwarz MI. Diffuse alveolar hemorrhage and systemic lupus erythematosus. Clinical presentation, histology, survival, and outcome. Medicine (Baltimore). 1997. 76:192–202.
Article
5. Niles JL, Bottinger EP, Saurina GR, Kelly KJ, Pan G, Collins AB, McCluskey RT. The syndrome of lung hemorrhage and nephritis is usually an ANCA-associated condition. Arch Intern Med. 1996. 156:440–445.
Article
6. Travis WD, Colby TV, Lombard C, Carpenter HA. A clinicopathologic study of 34 cases of diffuse pulmonary hemorrhage with lung biopsy confirmation. Am J Surg Pathol. 1990. 14:1112–1125.
Article
7. Nadrous HF, Yu AC, Specks U, Ryu JH. Pulmonary involvement in Henoch-Schonlein purpura. Mayo Clin Proc. 2004. 79:1151–1157.
8. Fung M, Churchill D, Alexopoulou I, Ingram A. IgA nephropathy and pulmonary hemorrhage in an adult. Am J Nephrol. 2001. 21:318–322.
Article
9. Loughlin GM, Taussig LM, Murphy SA, Strunk RC, Kohnen PW. Immune-complex-mediated glomerulonephritis and pulmonary hemorrhage simulating Goodpasture syndrome. J Pediatr. 1978. 93:181–184.
Article
10. Gilboa N, McIntire S, Hopp L, Ellis D. Acute noncrescentic poststreptococcal glomerulonephritis presenting with pulmonary hemorrhage. Pediatr Nephrol. 1993. 7:147–150.
Article
11. Chugh KS, Gupta VK, Singhal PC, Sehgal S. Case report: poststreptococcal crescentic glomerulonephritis and pulmonary hemorrhage simulating Goodpasture's syndrome. Ann Allergy. 1981. 47:104–106.
12. Hahn RG, Knox LM, Forman TA. Evaluation of poststreptococcal illness. Am Fam Physician. 2005. 71:1949–1954.
13. Sarkissian A, Papazian M, Azatian G, Arikiants N, Babloyan A, Leumann E. An epidemic of acute postinfectious glomerulonephritis in Armenia. Arch Dis Child. 1997. 77:342–344.
Article
14. Salama AD, Levy JB, Lightstone L, Pusey CD. Goodpasture's disease. Lancet. 2001. 358:917–920.
Article
15. Salama AD, Dougan T, Levy JB, Cook HT, Morgan SH, Naudeer S, Maidment G, George AJ, Evans D, Lightstone L, Pusey CD. Goodpasture's disease in the absence of circulating anti-glomerular basement membrane antibodies as detected by standard techniques. Am J Kidney Dis. 2002. 39:1162–1167.
Article
16. Jara LJ, Vera-Lastra O, Calleja MC. Pulmonary-renal vasculitic disorders: differential diagnosis and management. Curr Rheumatol Rep. 2003. 5:107–115.
Article
17. Bosch X, Font J. The pulmonary-renal syndrome: a poorly understood clinicopathologic condition. Lupus. 1999. 8:258–262.
Article
18. Crausman RS, Achenbach GA, Pluss WT, O'Brien RF, Jennings CA. Pulmonary capillaritis and alveolar hemorrhage associated with the antiphospholipid antibody syndrome. J Rheumatol. 1995. 22:554–556.
19. Fukuda Y, Yamanaka N, Ishizaki M, Suzuki T, Masugi Y, Yajima G, Nagata T. Immune complex-mediated glomerulonephritis and interstitial pneumonia simulating Goodpasture's syndrome. Acta Pathol Jpn. 1982. 32:361–370.
Article
20. Green RJ, Ruoss SJ, Kraft SA, Duncan SR, Berry GJ, Raffin TA. Pulmonary capillitis and alveolar hemorrhage. Update on diagnosis and management. Chest. 1996. 110:1305–1316.
21. De Torrente A, Popovtzer MM, Guggenheim SJ, Schrier RW. Serious Pulmonary hemorrhage, glomerulonephritis and massive steroid therapy. Ann Intern Med. 1975. 83:218–219.
Article
22. Leatherman JW, Sibley RK, Davies SF. Diffuse intrapulmonary hemorrhage and glomerulonephritis unrelated to anti-glomerular basement membrane antibody. Am J Med. 1982. 72:401–410.
Article
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