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Kojima D, Yamaguchi S, Hashiguchi A, Hayashi K, Uchiyama K, Yoshimoto N, Adachi K, Nakayama T, Nishioka K, Tajima T, Morimoto K, Yoshino J, Yoshida T, Monkawa T, Kanda T, Itoh H. Case report: Importance of early and continuous tocilizumab therapy in nephrotic syndrome associated with idiopathic multicentric Castleman disease: A case series. Front Med (Lausanne) 2023; 9:1037032. [PMID: 36698794 PMCID: PMC9868391 DOI: 10.3389/fmed.2022.1037032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/14/2022] [Indexed: 01/10/2023] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is a systemic and polyclonal lymphoproliferative disease involving multiple organs, including the kidneys, due to the overproduction of interleukin-6 (IL-6). Recently, several reports have suggested that excessive IL-6 actions in iMCD could have a causal relationship with the development of diverse histopathological renal manifestations that cause nephrotic syndrome. However, the treatment for such cases remains unclear. We report a series of three cases of nephrotic syndrome due to iMCD that helps to delineate the importance of early and continuous therapy with the anti-interleukin-6 receptor antibody tocilizumab. First, treatment was suspended for infectious control, and the patient presented with nephrotic syndrome due to diffuse mesangial and endocapillary hypercellularity without immune deposits complicating acute kidney injury. Second, iMCD was treated with prednisolone alone. The patient suddenly developed nephrotic syndrome due to immune-complex glomerulonephritis, not otherwise specified, complicated with acute kidney injury. In the third case, nephrotic syndrome secondary to membranous glomerulonephritis was diagnosed, with a skin rash and IgE antibodies to tocilizumab, and was therefore treated with prednisolone alone. In contrast to the first two cases, the third progressed to end-stage renal disease on hemodialysis. Taken together, this series suggests that clinicians should maintain clinical vigilance for iMCD as a possible underlying component of nephrotic syndrome, since iMCD presents with a variety of renal pathologies. Prompt initiation and continuous administration of tocilizumab are likely key determinants of renal outcomes in such cases. In particular, when tocilizumab is suspended due to infection or in the perioperative period, consideration of its expeditious resumption should be made, taking into account both the withdrawal period and systemic conditions.
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Affiliation(s)
- Daiki Kojima
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Yamaguchi
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan,*Correspondence: Shintaro Yamaguchi,
| | - Akinori Hashiguchi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Kaori Hayashi
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kiyotaka Uchiyama
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Norifumi Yoshimoto
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keika Adachi
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takashin Nakayama
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ken Nishioka
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takaya Tajima
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kohkichi Morimoto
- Apheresis and Dialysis Center, Keio University School of Medicine, Tokyo, Japan
| | - Jun Yoshino
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, Keio University School of Medicine, Tokyo, Japan
| | - Toshiaki Monkawa
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan,Medical Education Center, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Kanda
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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A Case of Castleman's Disease during the Long-Term Course of Membranous Nephropathy. Case Rep Nephrol 2023; 2023:4926000. [PMID: 36873956 PMCID: PMC9977547 DOI: 10.1155/2023/4926000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/24/2023] Open
Abstract
Concomitant with nephrotic syndrome and multicentric castleman's disease (MCD) has only been described in a limited number of small studies and case reports. Among those, none confirmed the renal pathology prior to the onset of MCD, and none of the cases had a history of nephrotic syndrome. A 76 year-old Japanese man visited a nephrologist because of incident nephrotic syndrome. He had previously experienced three episodes of nephrotic syndrome, the last one 13 years ago, and had been diagnosed with membranous nephropathy by renal biopsy. Apart from these previous episodes, he also suffered from systemic lymphadenopathy, anemia, elevated C-reactive protein, polyclonal hypergammopathy, and elevated interleukin (IL)-6. An inguinal lymph node biopsy revealed CD138-positive plasma cells in the interfollicular region. Based on these findings, MCD was diagnosed. Renal biopsy indicated primary membranous nephropathy with spike lesions and bubbling in the basement membranes and deposition of immunoglobulin (Ig) G, IgA, IgM, and phospholipase A2 receptor along the glomerular basement membrane. Corticosteroid monotherapy successfully reduced the edema, proteinuria, and IL-6, but hypoalbuminemia was not sufficiently improved due to castleman's disease and remission of the nephrotic syndrome was not achieved. Later, tocilizumab was administered for remission induction in another facility. To the best of our knowledge, this represents the first report of Castleman's disease with previously diagnosed membranous nephropathy. This case does not provide a causal mechanism for the pathophysiology, but it may be worth suggesting possible involvement of MCD as a trigger for recurrence of membranous nephropathy.
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Imamura K, Kojima S, Imamura T, Tsujita K. Recovery from AA amyloidosis-cardiomyopathy complexed with unicentric Castleman disease. BMJ Case Rep 2022; 15:e250338. [PMID: 35981748 PMCID: PMC9394191 DOI: 10.1136/bcr-2022-250338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of cardiac amyloid A (AA) amyloidosis due to unicentric Castleman disease (UCD) in a patient whose cardiac function was restored 15 years after surgical resection of the mesenteric lymph node lesion. A man in his 40s had recurrent palpitations and fainting spells. ECG revealed torsades de pointes Increased C-reactive protein, interleukin-6 and serum AA levels, and marked concentric thickening of the left ventricular (LV) wall with diastolic restrictive filling pattern were observed. Duodenal biopsy revealed AA amyloid deposits. He had a mesenteric tumour, comprising many plasma cells. He was diagnosed with plasma cell-type UCD associated with secondary AA amyloidosis. C-reactive protein, interleukin-6 and serum AA levels were normalised 2 months postresection. Episodes of lethal ventricular arrhythmias decreased. LV wall thickness was gradually reduced. Approximately 15 years postresection, the LV wall thickness nearly normalised and ventricular arrhythmias disappeared. Better outcomes are expected following surgical tumour resection.
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Affiliation(s)
- Kanako Imamura
- Department of Laboratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Sunao Kojima
- Department of Internal Medicine, Sakura-jyuji Yatsushiro Rehabilitation Hospital, Yatsushiro, Japan
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Kondo J, Arinuma Y, Matsueda Y, Hasegawa Y, Muramatsu T, Kanayama Y, Hoshiyama T, Tono T, Tanaka S, Oku K, Yamaoka K. A Patient with Castleman's Disease Initially Manifesting Symmetrical Synovitis with Pitting Edema. Mod Rheumatol Case Rep 2022; 6:309-313. [PMID: 35092673 DOI: 10.1093/mrcr/rxac003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/21/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022]
Abstract
Castleman's disease (CD), especially multicentric CD (MCD) has been known to manifest a variety of clinical features such as fatigue, anemia, fever and hypergammaglobulinemia. Here, we report a 72-year-old female patient who had complicated severe synovitis, as an initial manifestation of the disease, lastly diagnosed as MCD. Initially, she had been diagnosed as remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome because of bilateral leg pitting edema with significant c-reactive protein and matrix metalloproteinase-3 elevation but no disease-specific autoantibodies. Promptly, corticosteroid (CS) and additionally weekly methotrexate (MTX) was introduced, but her leg edema and inflammatory findings did not adequately come to be a remission. A lymph node biopsy from the groin region was performed because multiple lymph node swelling in ultrasound examination appeared even after introducing treatments, which revealed mixed-type CD. Multiple lymphadenopathies were observed in the axilla and inguinal region, finally, we diagnosed her as idiopathic MCD and introduced tocilizumab (TCZ) which significantly improved leg edema as well as inflammatory findings. As is shown in this case, manifestations included in RS3PE syndrome could be one of the clinical phenotypes in MCD, which should be considered as a differential diagnosis of MCD.
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Affiliation(s)
- Junichi Kondo
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshiyuki Arinuma
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yu Matsueda
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yasuhiro Hasegawa
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Takumi Muramatsu
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshiro Kanayama
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Takayuki Hoshiyama
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Toshihiro Tono
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sumiaki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
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Membranous nephropathy associated with multicentric Castleman's disease that was successfully treated with tocilizumab: a case report and review of the literature. BMC Nephrol 2021; 22:216. [PMID: 34107915 PMCID: PMC8191014 DOI: 10.1186/s12882-021-02423-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 06/03/2021] [Indexed: 12/14/2022] Open
Abstract
Background Multicentric Castleman’s disease is a life-threatening disorder involving a systemic inflammatory response and multiple organ failure caused by the overproduction of interleukin-6. Although renal complications of Castleman’s disease include AA amyloidosis, thrombotic microangiopathy, and membranoproliferative glomerulonephritis, membranous nephropathy is relatively rare. We experienced a case of secondary membranous nephropathy associated with Castleman’s disease. Case presentation The patient was a 43-year-old Japanese man who had shown a high zinc sulfate value in turbidity test, polyclonal hypergammaglobulinemia, anemia, and proteinuria. A physical examination revealed diffuse lymphadenopathy, an enlarged spleen and papulae of the body trunk. A skin biopsy of a papule on the patient’s back showed plasma cells in the perivascular area and he was diagnosed with multicentric Castleman’s disease, plasma cell variant. Kidney biopsy showed the appearance of bubbling in the glomerular basement membranes in Periodic acid methenamine silver stain and electron microscopy revealed electron dense deposits within and outside the glomerular basement membranes. Since immunofluorescence study showed predominant granular deposition of IgG1 and IgG2, he was diagnosed with secondary membranous nephropathy associated with Castleman’s disease. He was initially treated with prednisolone alone, however his biochemical abnormalities did not improve. After intravenous tocilizumab (700 mg every 2 weeks) was started, his C-reactive protein elevation, anemia, and polyclonal gammopathy improved. Furthermore, his urinary protein level declined from 1.58 g/gCr to 0.13 g/gCr. The prednisolone dose was gradually tapered, then discontinued. He has been stable without a recurrence of proteinuria for more than 6 months. Conclusions Tocilizumab might be a treatment option for secondary membranous nephropathy associated with Castleman’s disease.
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Tosaki T, Okabe M, Suzuki T, Shimizu A, Koike K, Tsuboi N, Kawamura T, Ohashi R, Yano S, Yokoo T. Membranous nephropathy with thrombotic microangiopathy-like lesions successfully treated with tocilizumab in a patient with idiopathic multicentric Castleman disease. CEN Case Rep 2021; 10:265-272. [PMID: 33389670 DOI: 10.1007/s13730-020-00559-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/09/2020] [Indexed: 01/13/2023] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is a systemic lymphoproliferative disease involving multiple organs, including the kidneys. Membranous nephropathy (MN) has been rarely reported as a complication of iMCD. We herein report the case of a 48-year-old man with a 9-year history of iMCD that was complicated by treatment-resistant nephrotic syndrome due to MN. The first renal biopsy performed at the age of 45 years showed diffuse and global MN with a mild glomerular endothelial injury. He was treated with combined therapy of corticosteroids, immunosuppressants, and tocilizumab, an anti-interleukin-6 (IL-6) receptor monoclonal antibody, which was administered every 2-3 weeks. However, nephrotic syndrome persisted, and renal impairment slowly worsened. Serial biopsy performed at 3 years after the first biopsy confirmed advanced lesions of both MN-related and glomerular endothelial injuries. Modification of the therapeutic strategy to weekly administration of tocilizumab gradually led to the remission of proteinuria, allowing the termination of corticosteroids. Thus, the present case suggests a close link between excessive IL-6 actions and the development of glomerular lesions in iMCD. Successful treatment by strict inhibition of IL-6 actions, in this case, may provide a clue for deciding the therapeutic strategy for severe renal complications associated with iMCD.
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Affiliation(s)
- Takeshi Tosaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Masahiro Okabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan.
| | - Tomo Suzuki
- Department of Nephrology, Kameda Medical Center, Kamogawa, Japan.,Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Akihiro Shimizu
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Tetsuya Kawamura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Ryuji Ohashi
- Department of Diagnostic Pathology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
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Pan Y, Cui Z, Wang S, Zheng D, Deng Z, Tian X, Guo H, Bao W, Zhou S, Wang Y. Idiopathic multicentric Castleman disease with Sjögren's syndrome and secondary membranous nephropathy: a case report and review of the literature. BMC Nephrol 2020; 21:528. [PMID: 33276741 PMCID: PMC7718671 DOI: 10.1186/s12882-020-02191-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 11/29/2020] [Indexed: 12/20/2022] Open
Abstract
Background Idiopathic multicentric Castleman disease (iMCD) is an uncommon lymphoproliferative disorder and lacks treatment consensus. Herein, we report a case of iMCD complicated with Sjögren’s syndrome (SS) and secondary membranous nephropathy (SMN). Case presentation A 45-year-old female with dry mouth for 3 months and anasarca and proteinuria for 2 months was admitted. She also experienced chest tightness, wheezing, fever, weight loss, moderate proteinuria and hypoalbuminemia. A computed tomography (CT) scan revealed a tissue mass in the thymus area and enlarged multiple lymph nodes. Her symptoms did not improve after resection of the thymus mass. The pathological findings were “reactive hyperplasia of the mediastinal lymph nodes and thymic hyperplasia”. Lymph node biopsy findings confirmed iMCD with human herpes virus-8 (HHV-8) negativity. Based on anti-nuclear antibody (ANA) 1:320, anti-SSA and anti-SSB antibody positivity, salivary flow less than 0.1 ml/min and lip biopsy with focal lymphocytic sialadenitis, SS was diagnosed. Kidney biopsy showed secondary membranous nephropathy with endocapillary cell proliferation and infiltration of plasma cells and lymphocytes in the tubulointerstitium. Serum interleukin-6 (IL-6) levels were significantly increased, and therapy with tocilizumab (anti-IL-6 receptor antibody) worked well. The combination of cyclophosphamide (CyS) with methylprednisolone (MP) maintained satisfactory remission. Conclusions Our case of iMCD with SS and SMN is rare. There is a need for increased awareness of the disease to avoid unnecessary procedures and misdiagnoses. IL-6 was extremely high, and there was a rapid response to anti-IL-6 receptor agents. The combination of CyS with MP maintained complete remission.
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Affiliation(s)
- Yuejuan Pan
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Zhuan Cui
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Song Wang
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Danxia Zheng
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Zhenling Deng
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Xinyu Tian
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Hongxia Guo
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Wenhan Bao
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Sijia Zhou
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China
| | - Yue Wang
- Department of Nephrology, Peking University Third Hospital, 49 Huayuanbei Road, Beijing, 100191, PR China.
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