A hemodialysis patient with PR3-ANCA/MPO-ANCA-positive cresentic glomerularnephritis and extrapulmonary lymph node tuberculosis

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  • Yasuda Mako
    Department of Medicine, Shiga University of Medical Science
  • Isshiki Keiji
    Department of Medicine, Shiga University of Medical Science Division of Blood Purification, Shiga University of Medical Science
  • Sakaguchi Masayoshi
    Department of Medicine, Shiga University of Medical Science
  • Kanasaki Masami
    Department of Medicine, Shiga University of Medical Science Division of Blood Purification, Shiga University of Medical Science
  • Kato Noriko
    Department of Medicine, Shiga University of Medical Science
  • Yamahara Kousuke
    Department of Medicine, Shiga University of Medical Science
  • Takagi Ayano
    Department of Medicine, Shiga University of Medical Science
  • Iwai Tamaki
    Department of Medicine, Shiga University of Medical Science
  • Ueda Hisami
    Department of Medicine, Shiga University of Medical Science
  • Araki Shin-ichi
    Department of Medicine, Shiga University of Medical Science
  • Sugimoto Toshiro
    Department of Medicine, Shiga University of Medical Science
  • Okada Yusaku
    Division of Blood Purification, Shiga University of Medical Science
  • Uzu Takashi
    Department of Medicine, Shiga University of Medical Science Division of Blood Purification, Shiga University of Medical Science

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Other Title
  • ＰＲ３‐ＡＮＣＡ，ＭＰＯ‐ＡＮＣＡともに陽性の半月体形成性糸球体腎炎に肺外リンパ節結核の関与が示唆された透析導入患者の１例
  • 症例報告 PR3-ANCA,MPO-ANCAともに陽性の半月体形成性糸球体腎炎に肺外リンパ節結核の関与が示唆された透析導入患者の1例
  • ショウレイ ホウコク PR3 ANCA MPO ANCA トモニ ヨウセイ ノ ハンゲツタイ ケイセイセイ シキュウタイジンエン ニ ハイ ガイ リンパセツ ケッカク ノ カンヨ ガ シサ サレタ トウセキ ドウニュウ カンジャ ノ 1レイ

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A 54-year-old man was admitted because the serum creatinine level had increased from 1.2 mg/dL to 5.15 mg/dL within 10 months. Histological examination of renal biopsy demonstrated crescentic glomerulonephritis with deposit of immunoglobulin A in the mesangial area. He was diagnosed as immunoglobulin A nephropathy associated with proteinase3-antineutrophil cytoplasmic antibody (PR3-ANCA) -associated glomerulonephritis. He was followed in our outpatient clinic without medications such as steroids or immunosuppressive drugs. Two months after discharge, his serological test also showed the elevation of myeloperoxidase (MPO) -ANCA level. Four months later, he was admitted again with complaints of low grade fever, anorexia, anemia, body weight loss, and general malaise. His laboratory investigation showed elevations of creatinine and CRP. Chest X-ray demonstrated pleural effusion and cardiomegaly. Hemodialysis was initiated. Chest CT scan on the second admission showed bilateral supraclavicular, mediastinal, and paraaortic lymphadenopathy. Light microscopic examination of the left supraclavicular lymph node, “Virchow-Troisier's node” biopsy demonstrated necrotizing granulomatous inflammation with Langerhans type giant cells. Polymerase chain reaction assay of the tissue sample was positive for Mycobacterium tuberculosis. This patient was diagnosed as having extrapulmonary lymph node tuberculosis and treated with the anti-tuberculous drugs, rifampin, isoniazid, ethambutol and pyrazinamide, resulting in a reduction in the sizes of all lymph nodes. When ANCA level increases again or reappearsed in patient with end stage renal disease, active tuberculosis should be considered in the differential diagnosis, because it is possible that tuberculosis causes a positive serological test for ANCA.

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