Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 15-1983. A 24-year-old man with cervical lymphadenopathy and the nephrotic syndrome

Concurrent FSGS and Hodgkin's lymphoma: case report and literature review on the link between nephrotic glomerulopathies and hematological malignancies

BACKGROUND

The link between the nephrotic syndrome (NS) and malignancy was first described in 1922. In solid tumors, the NS is most often due to membranous glomerulonephropathy, whereas in common hematological malignancies, minimal-change disease predominates. Focal segmental glomerulosclerosis (FSGS) is among the least frequently reported renal lesion associated with malignancy.

METHODS

We report a case of the simultaneous diagnoses of FSGS and Hodgkin's lymphoma, and review the literature on various nephrotic glomerulonephropathies associated with common leukemia and lymphoma.

RESULTS

Although nephrotic glomerulonephropathies rarely occur in association with acute leukemia, they have often been described in chronic lymphocytic leukemia (CLL). Membranoproliferative glomerulonephropathy and membranous glomerulonephropathy are the most common lesions observed in CLL. Nephrotic glomerulonephropathies have also been well documented among patients with lymphomas, in particular, Hodgkin's lymphoma. While minimal-change disease is most commonly found in association with Hodgkin's lymphoma, more diverse and complex renal lesions are associated with non-Hodgkin's lymphoma. FSGS remains a rare association with hematological malignancies.

CONCLUSIONS

Nephrotic glomerulonephropathies are not only linked to solid-organ tumors, but also to hematological malignancies. A thorough evaluation, including a physical examination for lymphadenopathy and organomegaly, as well as a hematological evaluation, must be performed in all patients presenting with nephrotic glomerulonephropathies.

Precipitable immune complexes in Hodgkin's disease

Sera from 28 untreated patients with Hodgkin's disease and from 120 healthy controls were investigated for the presence of circulating immune complexes using a modified 3% polyethylene glycol precipitation method with subsequent quantification of the precipitated protein. Elevated levels of precipitable protein were found in 79% (p less than 0.005) of Hodgkin's disease sera. The degree of elevation was associated with disease activity including the presence of B-symptoms. Constant and pronounced increase of precipitable protein was found in six patients with stage-III B nodular sclerosis subtype, thus exceeding the average amount of precipitable protein in healthy controls by a factor of 3-4. The erythrocyte sedimentation rate in 20 patients correlated with the amount of precipitable protein (r = 0.79). Additionally, partial component analysis of the precipitates was carried out by laser nephelometry. Immunoglobulins and complement components were identified as being major components of the precipitated material in sera both from patients and healthy controls, thus confirming the probability of the immune complex nature of the precipitates. Significant differences between patients and healthy controls concerned the amount of precipitable components. Elevation of precipitable IgM was found to be the most sensitive parameter (86% above means + 2 SD of normal controls, p less than 0.005). Increased amounts of precipitable IgG, C4, and Clq were found in 57-46% of patients' sera. Elevation of precipitable IgA and C3c were identified less often. The results suggest the quantification of precipitable immune complexes and their components to be of value as adjuncts in determining disease activity in Hodgkin's disease.