The nephrotic syndrome in secondary syphilis: report of a case with renal biopsy findings

A case of secondary syphilis demonstrating nephrotic syndrome and a solitary intrahepatic mass in a human immunodeficiency virus-1-infected patient

A 37-year-old, human immunodeficiency virus-1-infected Japanese man was referred because of nephrotic syndrome following emergence of generalized skin rash. Serological tests for syphilis turned out to be positive within ten months of the referral. Abdominal echography incidentally revealed a solitary intrahepatic mass without a detectable blood flow in segment 7. The patient's signs and symptoms, as well as the intrahepatic mass, resolved promptly after administration of amoxicillin. We consider that, in the present case, secondary syphilis caused the nephrotic syndrome and the intrahepatic mass, both of which have rarely been reported to date.

Early syphilitic hepatitis concomitant with nephrotic syndrome followed by acute kidney injury

Although acute hepatitis and nephrotic syndrome are commonly reported as complications of tertiary syphilis, nephrotic syndrome concomitant with hepatitis in early-stage syphilis is rare. Here, we describe the case of a 46-year-old male who was diagnosed with acute liver dysfunction and nephrotic syndrome after presenting with general malaise, and who subsequently developed acute kidney injury. Laboratory examination showed alkaline phosphatase had a greater magnitude of elevation compared to alanine aminotransferase, suggesting the possibility of syphilitic hepatitis. The rapid plasmin regain test and Treponema pallidum hemagglutination assay were positive, supporting the presence of a syphilis infection. Additionally, liver biopsy examination showed infiltration of inflammatory cells into the portal area and epithelioid cell granulomas. Moreover, kidney biopsy examination by both optical and electron microscopy showed a congestion of neutrophils in the capillary vessels, structural collapse of the tubules, and subepithelial deposits under the epithelium of the glomerular endothelial cells. These pathological changes were consistent with those reported previously for early syphilitic hepatitis and nephrotic syndrome in early-stage syphilis. All the symptoms, including liver and renal dysfunction, resolved after benzyl penicillin treatment was initiated. Hence, we believe early-stage syphilis should be included in the differential diagnosis of unknown liver damage and/or nephrosis.

Congenital nephrotic syndrome—a treatable cause

A 27-day-old infant from a tribal area presented with congenital nephrotic syndrome (CNS). The presence of clinical features of syphilis, proven syphilis in the mother and complete recovery following penicillin therapy confirmed a diagnosis of congenital syphilis. In developing countries, treatable causes of CNS such as syphilis need to be considered in infants presenting with nephrotic syndrome.

Experimental syphilis in guinea pig

The infrequent use of guinea pig in experimental syphilis, the not well genetically and immunologically characterized strains of animals originating from places with unspecified conditions of husbandry, and the various strains of Treponema pallidum used for infection provided inconsistent and discouraging results. For eight decades the rabbit has been the major animal model in studies of syphilis. However, the lack of readily available inbred strains of rabbits--necessary for adoptive transfer experiments--has been a stumbling block in revealing the mechanisms responsible for immunity, susceptibility, and resistance to T. pallidum infection. These difficulties have recently been overcome by demonstration of inbred strains susceptible to T. pallidum infection, paving the way to studies of adoptive immunity. The guinea pig may also be a better model than the rabbit for immunomanipulations (irradiation, injection with antibodies specific to various cell populations), allowing a closer insight into the immunopathologic mechanism operating during the course of syphilitic infection. The "rediscovery" of the guinea pig as a model for experimental syphilis and recent years of intensive studies justify a review summarizing older data and providing the most recent information. The authors, having first-hand experience with this model, will provide detailed information on (1) historical background; (2) course of infection with T. pallidum in inbred and outbred strains of guinea pigs; (3) the ID50 for various strains; (4) various routes of infection; (5) age and sex-dependent susceptibility to infection; (6) kinetic of the humoral response to specific and non-specific treponemal antigens; (7) appearance of autoantibodies and immune complexes; (8) cellular response, including lymphoproliferative response, macrophage inhibitory factor(s) production, chemotaxis and adoptive transfer of immunity by purified T cells; and (9) a complete list of references.

Circulating immune complexes in experimental syphilis: identification of treponemal antigens and specific antibodies to treponemal antigens in isolated complexes

As a prelude to characterization of the host and treponemal antigens present in purified immune complexes from the sera of rabbits with disseminated syphilis, autoradiographic and immunoenzymatic analyses of solubilized extracts of Treponema pallidum, Treponema phagedenis biotype Reiter, and Treponema refringens were performed on electroblots of polypeptides first separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Electroblots of purified immune complexes were developed with the same panel of antisera so that protein profiles could be compared. Eight treponemal antigens were consistently present in isolated complexes; four of these cross-reacted with antisera prepared against avirulent treponemes. The average molecular weights of these antigens were 87,000, 76,000, 66,000, and 45,000. Antibodies dissociated from isolated immune complexes, when used for the development of T. pallidum electroblots, reacted with four antigens of comparable molecular weight. Antibodies to those polypeptides were also present in the sera of animals immunized with immune complexes. The demonstration of treponemal antigens in purified immune complexes convincingly argues that their occurrence in experimental syphilis is not merely due to tissue destruction and responses to endogenous host antigens.

Simultaneous hepatic and renal involvement in acute syphilis. Case report and review of the literature

An unusual case of simultaneously occurring acute syphilitic hepatic and renal disease is presented and a concise literature review of both the pathological and clinical findings in this disease is included. Hepatic and renal biopsies were useful in excluding other diagnostic possibilities and in establishing the correct diagnosis in the case presented.

Free "small" and IgG-associated "large" hepatitis B e antigen in the serum and glomerular capillary walls of two patients with membranous glomerulonephritis

Nephrotic syndrome developed in two children who carried hepatitis B virus. Both their serums contained hepatitis B surface antigen and hepatitis B e antigen (HBeAg). Two physicochemically and immunologically different categories of HBeAg activity were identified in their serums--i.e., small molecular (free) and large molecular (associated with IgG). Their kidney-biopsy specimens disclosed pathologic changes typical of membranous glomerulonephritis. By a fluorescent-antibody technic, HBeAg was found to be deposited in diffuse granular fashion, along glomerular capillary walls together with IgG and beta1C, but no deposition of hepatitis B surface antigen was detected. The presence of HBeAg in association with IgG both in the serum and in the kidneys of these patients suggests that HBeAg caused membranous glomerulonephritis by inducing the formation and deposition of immune complexes.

Circulating immune complexes in syphilitic nephropathy. A case report

A case of transient nephrotic syndrome caused by secondary syphilis is described. A renal biopsy was performed revealing subepithelial hump-like electron-dense deposits and fusion of epithelial foot-processes. Complement C1q-binding-activity and anticomplementarity were demonstrated in the blood, indicating the presence of circulating immune complexes. This strongly suggests that circulating immune complexes are significant in the immunopathogenesis of syphilitic nephropathy.

Demonstration by labeled treponemal antigen of specific antibodies in the tissue infiltrates of secondary syphilis

Specific antitreponemal antibodies have been demonstrated by immunofluorescence techniques in the lymphoplasmocytic infiltrates which characterize early symphilitic lesions. A purified suspension of Nichols strain Treponema pallidum was sonified and labeled with fluorescein isothiocyanate and applied to cryostat sections of 12 biopsy specimens from the cutaneous lesions of 11 patients with proven secondary syphilis, using a modified direct immunofluorescence procedure. Specimens from various inflammatory dermatoses processed similarly served as controls. Granular fluorescence was noted in the dermis in 9 of the 12 specimens corresponding to areas of heavy plasma cell infiltration and some fluorescence was found directly on plasma cells which were identified by subsequent hematoxylin and eosin staining. This fluorescence could be blocked by prior incubation of the sections with unlabeled sonified treponemal suspension. Control slides did not reveal any fluorescence. The use of labeled treponemal antigen may aid the tissue diagnosis of early syphilitic lesions which can mimic a variety of dermatological disorders.

The pathogenesis of experimental membranous glomerulonephritis induced with homologous nephritogenic tubular antigen

The renal tubular epithelial antigen (Tub-Ag) of rats was solublized by Pronase and purified by gel filtration and acrylamide gel electrophoresis. Purified Tub-Ag was a glycoprotein with S20,W value of 8.4. Utilizing radiolabeled Tug-Ag, a sensitive radioimmunoassay for Tub-Ag and homologous antibody (anti-Tub-Ag) was developed. Tub-Ag activity associated with a protein of the same molecular size was demonstrated in the serum, as well as in Pronase extracts of all the organs tested, including kidney, liver, lung, spleen, intestine, stomach, and heart. The physiochemical properties of the Tub-Ag of rats and its distribution were essentially the same as the Tub-Ag of humans, which had been found in immune deposits in the kidney of some patients with idiopathic membranous glomerulonephritis. Rats were immunized with the purified Tub-Ag emulsified in Freund's complete adjuvant and followed for Tub-Ag and anti-Tub-Ag in the serum, as well as for proteinuria and immunohistological changes in the kidney. Serum Tub-Ag dropped sharply after 20 days, when anti-Tub-Ag appeared in the circulation. Persistent, massive proteinuria appeared still later, more than 30 days after injection, when anti-Tub-Ag disappeared and Tub-Ag reappeared in the serum of some of those rats. In others, anti-Tub-Ag in the serum persisted throughout the observation period of 90 days. The pathology of the kidney of the rats with proteinuria was that of a typical membranous glomerulonephritis; thickening of glomerular capillary walls with granular deposits of gamma-globulin and Tub-Ag was observed. On the basis of these results, Tub-Ag in the serum, probably released from cellular membranes of various organs as a physiological metabolite, is considered to maintain the pathological process in the kidney by providing the antigen continuously to form immune complexes.

Congenital syphilis and glomerulonephritis with evidence for immune pathogenesis

In 3 infants with congenital syphilis the dominant clinical manifestation of syphilitic kidney disease was the nephrotic syndrome. Mesangioendothelial proliferation was present in 2 cases and mixed proliferative glomerulonephritis with crescent formation in the third. The severity of the clinical and histopathological abnormalities could be related to the apparent duration of the illness. In all 3 cases immune complex deposition could be shown within and along the epithelial aspect of the glomerular basement membrane on light, electron, and immunofluorescent microscopy. These features, together with a reduced total serum haemolytic complement, suggest an immune pathogenesis of the glomerulonephritis associated with early congenital syphilis.

Nephrotic syndrome in congenital syphilis

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Nephrotic syndrome: a complication of secondary syphilis

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