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Jamboti JS, Sinniah R, Dorsogna L, Holmes C. Recurrent, Atypical Anti-Glomerular Basement Membrane Disease. Indian J Nephrol 2021; 31:319-321. [PMID: 34376954 PMCID: PMC8330667 DOI: 10.4103/ijn.ijn_414_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 05/06/2020] [Accepted: 05/23/2020] [Indexed: 11/06/2022] Open
Abstract
Anti-glomerular basement membrane disease (GBM) (Goodpasture's disease) typically presents with acute manifestations of rapidly progressive glomerulonephritis often accompanied by lung haemorrhage. Anti-GBM disease is usually monophasic. However, atypical presentations with indolent renal involvement are being increasingly recognized. Herein we report a patient who presented with lung haemorrhage, minimal renal involvement, and negative result for serum anti-GBM antibody, while immunofluorescence examination of the renal biopsy provided the diagnosis leading to the institution right treatment with excellent response. Interestingly, he had presented 10 years earlier with lung hemorrhage, more significant renal involvement clinically and histologically, with positive serum anti-GBM antibody. The present case is intended to increase our awareness regarding the variable presentations of anti-GBM disease, such as with negative serology and recurrence of anti-GBM disease. The presentation of anti-GBM nephritis with non-proliferative, non-crescentic glomerulonephritis is also highlighted. The possible explanations for negative serum anti-GBM antibody are explored with a brief review of literature.
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Affiliation(s)
- Jagadish S Jamboti
- Department of Nephrology and Transplantation, Curtin University, Bentley, Western Australia.,Curtin University, Bentley, Crawley, Western Australia.,University of Western Australia, Crawley, Western Australia
| | - Rajalingam Sinniah
- University of Western Australia, Crawley, Western Australia.,Department of Anatomical Pathology, Bendigo, Monash University Rural School of Health, Bendigo, Victoria, Western Australia
| | - Lloyd Dorsogna
- University of Western Australia, Crawley, Western Australia.,Clinical Immunology, Fiona Stanley Hospital, Murdoch, Western Australia
| | - Christian Holmes
- Nephrology Service, Bendigo, Monash University Rural School of Health, Bendigo, Victoria, Western Australia
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Adapa S, Konala VM, Hou J, Naramala S, Agrawal N, Dhingra H, Aronow WS. Seronegative atypical anti-glomerular basement membrane crescentic glomerulonephritis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:246. [PMID: 31317016 DOI: 10.21037/atm.2019.04.60] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 46-year-old female presented with a chief complaint of fatigue and intermittent painless gross hematuria for one month. The patient was fluid overloaded on physical examination and noted to be in acute renal failure with a serum creatinine of 10.8 mg/dL. The patient was emergently started on hemodialysis. Serologies were negative for antinuclear antibody (ANA), anti-neutrophilic cytoplasmic antibody (ANCA), and anti-glomerular basement membrane (anti-GBM) antibody. However, renal biopsy revealed 90% glomerular involvement by temporally heterogeneous crescents ranging from cellular to fibrous. Immunofluorescence studies revealed strong, linear glomerular capillary wall staining for immunoglobulin G (IgG). Although the patient was treated with pulse dose steroids and cyclophosphamide, the patient ultimately developed infectious complications from immunosuppression, and treatment was terminated. This case highlights the atypical presentation of anti-GBM disease diagnosed based on renal biopsy with negative serologies. Although rare, the possibility of atypical anti-GBM antibodies which are not detected by standard commercial assays should be considered in such cases.
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Affiliation(s)
- Sreedhar Adapa
- Division of Nephrology, The Nephrology Group, Fresno, CA, USA
| | - Venu Madhav Konala
- Department of Internal Medicine/Division of Medical Oncology, Ashland Bellefonte Cancer Center, Ashland, KY, USA
| | - Jean Hou
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Srikanth Naramala
- Division of Rheumatology, Adventist Medical Center, Hanford, CA, USA
| | - Nikhil Agrawal
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hemant Dhingra
- Department of Medicine, St Agnes Medical Center, Fresno, CA, USA
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Antibody-Negative Relapse of Goodpasture Syndrome with Pulmonary Hemorrhage. Case Rep Med 2019; 2019:2975131. [PMID: 31178913 PMCID: PMC6507154 DOI: 10.1155/2019/2975131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/23/2019] [Accepted: 04/07/2019] [Indexed: 11/20/2022] Open
Abstract
Goodpasture syndrome is a rare autoimmune disease comprising antiglomerular basement membrane (anti-GBM) crescentic glomerulonephritis and pulmonary capillaritis with circulating anti-GBM antibodies. Rarely, antibody-negative cases have been described. We report a young, African American adult woman admitted with flank pain and hematuria with laboratory testing and kidney biopsy demonstrating anti-GBM crescentic glomerulonephritis with elevated anti-GBM antibody levels. She received treatment but remained dialysis-dependent. She was seronegative and clinically stable until she presented 8 months later with dyspnea and hemoptysis requiring mechanical ventilation. Bronchoscopy revealed diffuse alveolar hemorrhage. She was treated for relapse of Goodpasture syndrome. However, anti-GBM antibodies were undetectable. This case emphasizes prompt diagnosis and treatment of Goodpasture syndrome to preserve renal function. Additionally, clinical manifestations of Goodpasture syndrome and its degree of activity do not necessarily correlate with the actual antibody titer on relapse. Clinicians should have enhanced awareness of this atypical presentation of a rare disease.
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Scollo V, Zanoli L, Russo E, Distefano G, Rapisarda F. A Case of Rare Diffuse Alveolar Hemorrhage and Review of Literature. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2017; 10:1179547617726077. [PMID: 29104431 PMCID: PMC5562341 DOI: 10.1177/1179547617726077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 07/07/2017] [Indexed: 12/01/2022]
Abstract
It is well known that some disorders can cause concomitant kidney dysfunction with lung involvement. These syndromes, characterized by the simultaneous presence of intra-alveolar hemorrhage and acute glomerulonephritis, are caused by numerous and variable disorders. The most frequent are the antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis and Goodpasture syndrome. A quick discerning of the underlying causes and initiation of adequate treatment is crucial to prevent acute respiratory failure and irreversible loss of renal function. We reported the case of a 33-year-old man having hemorrhagic alveolitis presenting a picture consistent with Goodpasture syndrome in the absence of anti-glomerular basement membrane (anti-GBM) antibodies or ANCA at lab test and a review of literature. This case highlights the need to consider the chances of falsely seronegative cases of anti-GBM disease, as well as the importance of using all available assay routine tests. These cases would appear indeed more common than before if just taken into consideration their existence. Several reports have shown false seronegatives especially in patients with relapses, in smokers, and in patients with predominantly pulmonary symptoms.
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Affiliation(s)
- Viviana Scollo
- Section of Nephrology, Division of Internal Medicine, Department of Clinical and Experimental Medicine, Policlinico Universitario, University of Catania, Catania, Italy
| | - Luca Zanoli
- Section of Nephrology, Division of Internal Medicine, Department of Clinical and Experimental Medicine, Policlinico Universitario, University of Catania, Catania, Italy
| | - Elisa Russo
- Section of Nephrology, Division of Internal Medicine, Department of Clinical and Experimental Medicine, Policlinico Universitario, University of Catania, Catania, Italy
| | - Giulio Distefano
- Section of Nephrology, Division of Internal Medicine, Department of Clinical and Experimental Medicine, Policlinico Universitario, University of Catania, Catania, Italy
| | - Francesco Rapisarda
- Section of Nephrology, Division of Internal Medicine, Department of Clinical and Experimental Medicine, Policlinico Universitario, University of Catania, Catania, Italy
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Glassock RJ. Atypical anti-glomerular basement membrane disease: lessons learned. Clin Kidney J 2016; 9:653-6. [PMID: 27679709 PMCID: PMC5036901 DOI: 10.1093/ckj/sfw068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 11/12/2022] Open
Abstract
Anti-glomerular basement membrane (GBM) disease usually pursues a self-limited course, at least from the immunological perspective. In addition, circulating antibodies to cryptic, conformational epitopes within the NC1 domain of the alpha 3 chain of Type IV Collagen are commonly found at the zenith of the clinical disease. However, exceptions to these general rules do occur, as exemplified by two remarkable cases reported in this issue of the Clinical Kidney Journal. The possible explanations for and the lessons learned from these uncommon occurrences are discussed in this short commentary.
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Affiliation(s)
- Richard J Glassock
- David Geffen School of Medicine at UCLA , Laguna Niguel, Los Angeles, CA , USA
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Gu B, Magil AB, Barbour SJ. Frequently relapsing anti-glomerular basement membrane antibody disease with changing clinical phenotype and antibody characteristics over time. Clin Kidney J 2016; 9:661-4. [PMID: 27679711 PMCID: PMC5036897 DOI: 10.1093/ckj/sfw048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/10/2016] [Indexed: 11/12/2022] Open
Abstract
Anti-glomerular basement membrane (GBM) antibody disease is a typically monophasic autoimmune disease with severe pulmonary and renal involvement. We report an atypical case of frequently relapsing anti-GBM antibody disease with both anti-GBM antibody-positive flares with pulmonary and renal involvement, and anti-GBM antibody-negative flares that were pulmonary limited with no histologic renal disease. This is the first report of alternating disease phenotype and anti-GBM antibody status over time. Disease severity paralleled the detection of anti-GBM antibodies but was independent of IgG subtype staining along the GBM. This case suggests a role for changing subpopulations of pathogenic antibodies as an explanation for variation in disease phenotype and anti-GBM antibody results.
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Affiliation(s)
- Bobby Gu
- Faculty of Medicine , University of British Columbia , Vancouver, BC , Canada
| | - Alex B Magil
- Department of Pathology and Laboratory Medicine , St. Paul's Hospital and University of British Columbia , Vancouver, BC , Canada
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, 5th Floor Nephrology, 2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9; BC Provincial Renal Agency, Vancouver, BC, Canada; Centre forHealth Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
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Troxell ML, Houghton DC. Atypical anti-glomerular basement membrane disease. Clin Kidney J 2015; 9:211-21. [PMID: 26985371 PMCID: PMC4792615 DOI: 10.1093/ckj/sfv140] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/17/2015] [Indexed: 12/23/2022] Open
Abstract
Background Anti-glomerular basement membrane (anti-GBM) disease classically presents with aggressive necrotizing and crescentic glomerulonephritis, often with pulmonary hemorrhage. The pathologic hallmark is linear staining of GBMs for deposited immunoglobulin G (IgG), usually accompanied by serum autoantibodies to the collagen IV alpha-3 constituents of GBMs. Methods Renal pathology files were searched for cases with linear anti-GBM to identify cases with atypical or indolent course. Histopathology, laboratory studies, treatment and outcome of those cases was reviewed in detail. Results Five anti-GBM cases with atypical clinicopathologic features were identified (accounting for ∼8% of anti-GBM cases in our laboratory). Kidney biopsies showed minimal glomerular changes by light microscopy; one patient had monoclonal IgG deposits in an allograft (likely recurrent). Three patients did not have detectable serum anti-GBM by conventional assays. Three patients had indolent clinical courses after immunosuppressive treatment. One patient, untreated after presenting with brief mild hematuria, re-presented after a short interval with necrotizing and crescentic glomerulonephritis. Conclusions Thorough clinicopathologic characterization and close follow-up of patients with findings of atypical anti-GBM on renal biopsy are needed. Review of the literature reveals only rare well-documented atypical anti-GBM cases to date, only one of which progressed to end-stage kidney disease.
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Affiliation(s)
- Megan L Troxell
- Department of Pathology , Oregon Health & Science University , Portland, OR , USA
| | - Donald C Houghton
- Department of Pathology , Oregon Health & Science University , Portland, OR , USA
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Kussman A, Gohara A. Serum antibody-negative Goodpasture syndrome with delta granule pool storage deficiency and eosinophilia. Clin Kidney J 2012; 5:572-5. [PMID: 26069804 PMCID: PMC4400547 DOI: 10.1093/ckj/sfs107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 07/18/2012] [Indexed: 01/30/2023] Open
Abstract
Goodpasture syndrome is a rare, life-threatening autoimmune disease characterized by a triad of rapidly progressive glomerulonephritis, a hemorrhagic pulmonary condition and the presence of anti-glomerular basement membrane (anti-GBM) antibodies. The antibodies initiate destruction of the kidney glomeruli, resulting in a focal necrotizing glomerulitis, which may progress rapidly to renal failure. Autoantibody-mediated damage of alveolar basement membranes leads to diffuse pulmonary hemorrhage, which in some cases may be severe enough to cause respiratory failure. Many clinicians use a variety of assays to detect serum anti-GBM antibodies; however, these tests may be falsely negative in up to 15% of patients with Goodpasture syndrome. Here, we report an unusual case of a 40-year-old man with clinical evidence of Goodpasture syndrome, a negative anti-GBM antibody serum result, eosinophilia and delta granule pool storage deficiency. After a 14-day hospital stay and extensive workup, as well as treatment with antibiotics, steroids and ventilator support for respiratory failure, the patient continued to deteriorate and entered multisystem organ failure. The family decided to withdraw ventilator support, and the patient expired. Immunofluorescence testing for anti-GBM autoantibodies on lung and kidney tissues during an autopsy confirmed the diagnosis of Goodpasture syndrome.
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Affiliation(s)
- Ashleigh Kussman
- Department of Pathology , University of Toledo Medical Center , Toledo, OH , USA
| | - Amira Gohara
- Department of Pathology , University of Toledo Medical Center , Toledo, OH , USA
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