Immune complex glomerulonephritis in a case of retroperitoneal fibrosis

L'eziopatogenesi della fibrosi retroperitoneale: Etiopathogenesis of retroperitoneal fibrosis

The etiopathogenesis of retroperitoneal fibrosis is still obscure and probably multifactorial. Among the secondary forms due to demonstrable causes, the one caused by aorto-iliac atherosclerosis has recently been recognised. Its pathogenesis is linked to the low density oxidised lipoproteins of the atheromatous plaque, which are responsible for a local immunologic reaction. The most common form is still idiopathic or primitive, hypothetically related to genetic, environmental, vascular and/or immunologic factors. Idiopathic retroperitoneal fibrosis is sometimes associated with other sclerosing syndromes and/or systemic diseases. In such cases a common pathogenesis, probably immunologic may be postulated. After having illustrated the different categories of retroperitoneal fibrosis, the authors report their experience with 25 patients of whom 14 had idiopathic fibrosis and 11 secondary fibrosis. In the former group 11 patients (78.5%) smoked more than 10 cigarettes a day, while there was a history of prolonged professional exposure to asbestos in one case. The following associated pathologies were observed: hypertension in 7 cases (50%), ischemic cardiopathy in 2 (14.3%), diabetes mellitus in 2 (14.3%), multiple myeloma in 1 (7.1%) and juvenile rheumatoid arthritis in 1 (7.1%). The disease was also associated with other sclerosing pathologies in 3 cases: sclerosing cholangitis in 2 and Dupuytren's contracture in 1. The location of the fibrosis was typically periaortic in 13 cases (92.8%), as shown by CT. Lastly, 10 patients underwent immunosuppressive therapy with a favourable response, suggesting the probable immunologic pathogenesis of the disease.

Idiopathic retroperitoneal fibrosis presented as an abdominal mass and nephrotic syndrome

We present a 30-year-old male patient who was initially diagnosed as minimal change nephrotic syndrome, 5 years later, the patient developed a localized form of idiopathic retroperitoneal fibrosis (IRF). An elevated ESR and concomitant nephrotic syndrome in the patient suggested the immunologic nature of IRF, IRF has been reported in association with collagen diseases and rarely with proliferative and nonproliferative glomerulopathies. To our knowledge, the association between minimal change lesion (MC) and IRF has not been reported. Furthermore, the fact that IRF presented itself as an abdominal mass and lacked systemic symptoms was also unusual.

Retroperitoneal fibrosis accompanying immune thrombocytopenia

Retroperitoneal fibrosis represents an idiopathic systemic fibrosing syndrome which leads to the development of progressive hydronephrosis and azotemia (Stewart and Friberg: Southern Medical Journal 77:1185-1187, 1984; Morad et al.: American Journal of Medicine 82:363-366, 1987). Evidence in the literature supports a hypothesis that retroperitoneal fibrosis represents a systemic autoimmune process (Lichon et al.: Journal of Rheumatology 11:373, 374, 1984; Lipman et al.: JAMA 196:204-206, 1966; Littlejohn and Keystone: Journal of Rheumatology 8:665-669, 1981; Katz et al.: American Journal of Clinical Pathology 67:436-439, 1977). We report a case of a patient with retroperitoneal fibrosis, immune thrombocytopenia, presence of antinuclear antibody, and direct Coombs positivity which provides further evidence that retroperitoneal fibrosis is an autoimmune process. Progressive obstructive uropathy related to his fibrosis led to bilateral hydronephrosis and significant renal function impairment. Also, he developed marked immune thrombocytopenia. Treatment with prednisone produced a dramatic response in both platelet count and renal function.

Treatment of idiopathic retroperitoneal fibrosis by immunosuppression

Idiopathic retroperitoneal fibrosis is exceedingly uncommon in childhood and its etiology is uncertain. Support for an immunological basis for the disease is given by a report of a 14-year-old girl with severe retroperitoneal fibrosis causing progressive azotemia in whom azathioprine and prednisolone were used successfully. This case supports the efficacy of immunotherapy in the treatment of idiopathic retroperitoneal fibrosis.

Tumefactive fibroinflammatory lesions of the head and neck

The term 'tumefactive fibroinflammatory lesion' has been used to describe a fibrosclerosing disorder which has a locally destructive nature but is characterized by a benign histological appearance. We report five patients, over a five year period, with such a lesion. The clinical behaviour and surgical findings suggest the lesion to be an invasive malignancy. However, the histological appearance of an admixture of chronic inflammatory cells and fibrosis is consistent with a benign condition. We recommend surgical excision of the lesion as the mainstay of treatment; other studies report the use of steroids and radiotherapy.

Idiopathic retroperitoneal and mediastinal fibrosis mimicking connective tissue disease

Combined retroperitoneal and mediastinal fibrosis is a rare manifestation of an idiopathic systemic sclerosing disease. This report describes a multisystem illness that clinically could best be described as polyserositis and progressive renal failure. Pathologically, it was characterized by diffuse infiltration of retroperitoneal and mediastinal tissues with plaquelike fibrofatty connective tissue encasing the kidneys, ureters, adrenal glands, and parietal pericardium. These features are diagnostic of a systemic sclerosing disease. It is important to recognize this unusual disorder to avoid confusion with other systemic connective tissue diseases such as systemic lupus erythematosus.

Retroperitoneal fibrosis: a two decade experience and gynecologic manifestations

A 20-year experience with idiopathic retroperitoneal fibrosis (RPF) is presented (6 cases). Its gynecologic manifestations with the simulation of pelvic malignancy is discussed. Three of the patients presented with pelvic masses, one of these a para-vaginal mass. In one patient, RPF followed or was concurrent with invasive squamous cell carcinoma of the cervix, of which this is the first reported case. The subject of RPF is reviewed with the modes of management and evidence for an autoimmune etiology. Thrombocytopenia, a previously unreported finding with RPF, was noted in three of the six patients. The reversal of the A/G ratio in these patients is discussed, correlating this finding with the progression of azotemia.

Renal manifestations of extrarenal neoplasms

In a study of 1270 consecutive autopsies there were 314 patients with malignant neoplasms arising in sites other than the kidney and central nervous system. In over 50 per cent of these there was significant renal damage related to cancer. Renal damage was produced by direct involvement of one or both kidneys by the neoplasm or by indirect effects. The latter included ischemic damage, metabolic injury, immunologic injury, and effects of therapy directed at the malignant tumor. In patients with cancer, tumor bulk and invasion of vital organs do not always explain the clinical deterioration and cause of death. Recognition of the indirect effects of tumors on the kidney and other organ systems is essential to the understanding of the generalized host response to malignant disease.

Idiopathic retroperitoneal fibrosis: a systemic connective tissue disease?

Renal histology of a patient with idiopathic retroperitoneal fibrosis demonstrated a proliferative crescentic glomerulonephritis with intramembranous electron-dense deposits. These findings were interpreted as being consistent with an immune complex glomerulonephritis. Serologic studies revealed a positive antismooth muscle antibody titer of 1:80 and a weakly positive antinuclear antibody titer of 1:40. No distinct systemic disease was identified. While fibrosis of the retroperitoneum can occur in association with a number of distinct pathologic conditions and pharmacologic agents, the mechanism responsible for the development of the idiopathic variety of retroperitoneal fibrosis remains unclear. Our observation of an immune complex glomerulonephritis and the cumulative data on idiopathic retroperitoneal fibrosis are consistent with the concept that the fibrosis may be a local expression of an immunologically mediated systemic disease.