An Unusual Case of Anti-Glomerular Basement Membrane Disease and Phospholipase A2 Receptor-Associated Membranous Nephropathy After Exposure to Hydrocarbons

We present a rare case of a patient with toluene exposure manifesting as anti-glomerular basement membrane (GBM) disease on a background of phospholipase A2 receptor (PLA2R)-associated membranous nephropathy. A 23-year-old man presented to the emergency department with hypertension, headache, hemoptysis, anemia, acute kidney injury, glomerular hematuria, and proteinuria. He endorsed repeated exposure to toluene-containing products while repairing dirt bikes. Serologies were positive for anti-GBM antibodies. Kidney biopsy showed crescentic glomerulonephritis with linear immunoglobulin G and granular PLA2R staining by immunofluorescence. He was initially treated with high-dose steroids, plasmapheresis, and hemodialysis for pulmonary-renal syndrome followed by oral cyclophosphamide and prednisone, which were discontinued after 3 months when follow-up biopsies confirmed little chance for renal recovery. He remained on dialysis 1 year later. This case exhibits a unique presentation of anti-GBM syndrome and underlying membranous nephropathy following repeated hydrocarbon exposure. Inhaled toxins promote recurrent localized inflammation, unmasking previously hidden epitopes. Early diagnosis and appropriate use of immunosuppressive and extracorporeal therapies are necessary to prevent morbidity and to improve survival in this rare condition.

Involvement of MCP-1 in Tubulointerstitial Fibrosis Through Massive Proteinuria in Anti-GBM Nephritis Induced in WKY Rats

We investigated participation of monocyte chemoattractant protein-1 (MCP-1) in tubulointerstitial fibrosis and correlation between MCP-1 and proteinuria in Wistar-Kyoto (WKY) rats with glomerulonephritis induced by anti-glomerular basement membrane (anti-GBM) antibody. WKY rats showed marked proteinuria and severe glomerular crescent formation at 7 days post antibody injection. At 28 days, tubulointerstitial fibrotic lesions were observed, followed by sustained heavy proteinuria and severe tubulointerstitial fibrosis at 56 days. Histological examination revealed that the overlapped immunoreactivities of MCP-1, rat albumin, and p65NF-kappaB were detected in the same tubular segments of nephritic kidney, and a significant positive correlation was observed between proteinuria and MCP-1 expression in the tubulointerstitial fibrosis. ED-1- and CD8-positive cells were also abundant, and there was a good correlation between monocyte/macrophage recruitment and MCP-1 expression in the tubulointerstitial area. These results suggest that MCP-1 participates in the progression of tubulointerstitial fibrosis, through massive albuminuria, which is accompanied by marked monocyte/macrophage recruitment.

Protective effect of ligustrazine on accelerated anti-glomerular basement membrane antibody nephritis in rats is based on its antioxidant properties

Ligustrazine has a renoprotective effect against nephritis. In this study, we further characterized the renoprotective properties of ligustrazine in an experimental model using accelerated anti-glomerular basement membrane antibody (AGBM-Ab). Ligustrazine was given i.p. once daily at 50, 100 mg/kg for 15 days after singly giving i.v. of rabbit anti-rat glomerular basement membrane serum, and showed dose-dependent inhibition the elevation of urinary protein, serum creatinine and blood urea nitrogen as well as the development of glomerular histological changes. Ligustrazine (50 mg/kg) had no affect on glutathione (GSH) content, glutathione peroxidase and catalase activities, but decreased the malondialdehyde (MDA) content and increased superoxide dismutase (SOD) activity in nephritis induced by AGBM-Ab. Ligustrazine (100 mg/kg) significantly decreased MDA content while significantly increased GSH content and SOD, glutathione peroxidase, catalase activities of kidney tissues in the rats treated with AGBM-Ab alone. In conclusion, our results show that ligustrazine has protective activity against accelerated AGBM-Ab nephritis, and its renoprotective effect may be due to its antioxidant properties and inhibition reactive oxygen species (ROS).

Calpain activation and secretion promote glomerular injury in experimental glomerulonephritis: evidence from calpastatin-transgenic mice

Glomerular injury and albuminuria in acute glomerulonephritis are related to the severity of inflammatory process. Calpain, a calcium-activated cysteine protease, has been shown to participate in the development of the inflammatory process. Therefore, for determination of the role of calpain in the pathophysiology of acute glomerulonephritis, transgenic mice that constitutively express high levels of calpastatin, a calpain-specific inhibitor protein, were generated. Wild-type mice that were subjected to anti-glomerular basement membrane nephritis exhibited elevated levels of calpain activity in kidney cortex at the heterologous phase of the disease. This was associated with the appearance in urine of calpain activity, which originated potentially from inflammatory cells, abnormal transglomerular passage of plasma proteins, and tubular secretion. In comparison with nephritic wild-type mice, nephritic calpastatin-transgenic mice exhibited limited activation of calpain in kidney cortex and limited secretion of calpain activity in urine. This was associated with less severe glomerular injury (including capillary thrombi and neutrophil activity) and proteinuria. There was a reduction in NF-kappaB activation, suggesting that calpain may participate in inflammatory lesions through NF-kappaB activation. There also was a reduction in nephrin disappearance from the surface of podocytes, indicating that calpain activity would enhance proteinuria by affecting nephrin expression. Exposure of cultured podocytes to calpain decreased nephrin expression, and, conversely, exposure of these cells to calpastatin prevented TNF-alpha from decreasing nephrin expression, demonstrating a role for the secreted form of calpain. Thus, both activation and secretion of calpains participate in the development of immune glomerular injury.

Goodpasture-like syndrome induced by D-penicillamine in a patient with systemic sclerosis: report and review of the literature

We report a case of Goodpasture-like syndrome developing in a patient who was treated with D-penicillamine for the diffuse form of systemic sclerosis. This unusual pulmonary-renal syndrome has been described on rare occasions in patients receiving D-penicillamine. This complication appeared to be uniformly fatal unless treated with aggressive immunotherapy. We review the cases reported to date in the literature and describe the clinical characteristics, therapy, and outcome of this group of patients.

Outcomes in patients with Goodpasture's syndrome and hydrocarbon exposure

Goodpasture's Syndrome has been associated with hydrocarbon exposure. No study has examined outcomes in these patients. All reported cases of Goodpasture's Syndrome and hydrocarbon exposure were identified using MEDLINE and was analyzed for factors related to outcomes. A total of 43 cases were identified since 1969. The mean age of patients was 28 years old. There was a slight predilection for males (60%) when analyzing gender. Various types of hydrocarbons were identified and the duration of exposure varied from minutes to years. A majority of patients (86%) had pulmonary hemorrhage and antiglomerular basement membrane antibodies (AGBM) (92%). Patients were treated with immunosuppressive agents. The only significant statistical correlation was female patients with hydrocarbon exposure were younger. There was no correlation between age, gender, duration of exposure, presence of pulmonary hemorrhage or AGBM, or other risk factors and outcome. The relationship between hydrocarbon exposure and Goodpasture's Syndrome remains unclear since only 6% of cases in the literature had exposure. Even though most patients survived, no factor studied affected outcome making it difficult to predict prognosis in these patients.

Protection and injury: the differing roles of complement in the development of glomerular injury

The role of complement in autoimmune glomerulonephritis (as in other autoimmune diseases) is paradoxical, in that complement activation mediates acute inflammatory injury, yet inherited deficiency of complement may predispose to immune complex disease in particular immune complex glomerulonephritis. We have investigated the role of complement in experimentally induced glomerulonephritis in C3-deficient mice, using antibodies against the mouse glomerular basement membrane (GBM). In the acute phase of the disease, which is initiated by binding of heterologous antibody to the GBM, we confirmed that the inflammatory injury was positively complement dependent, with C3-deficient mice developing less severe injury. In contrast, in the autologous phase of the disease, mediated by the immune response against the heterologous antibody fixed in the GBM, the disease was negatively complement dependent. That is, by 14 days after disease induction the C3-deficient mice had heavier proteinuria and more severe uremia (p < 0.001) compared to the complement sufficient mice. The C3-deficient mice also showed a greater accumulation of electron-dense deposits in the GBM. These findings were reproduced in an accelerated model of this disease in which C3-deficient mice also develop more severe functional disturbance and demonstrate a higher rate of immune complex deposition. These data illustrate the potential for the net effect of complement to switch from a detrimental to a protective mode at different stages of autoimmune injury.

Antiglomerular basement membrane antibody-mediated glomerulonephritis after intranasal cocaine use

We report a case of rapidly progressive glomerulonephritis due to antiglomerular basement membrane (anti-GBM) antibodies that progressed to end-stage renal disease in a 35-year-old man who used intranasal cocaine on an occasional basis. In contrast to many prior reports of acute renal failure occurring with cocaine-associated rhabdomyolysis, this patient did not have any evidence of acute muscle damage and myoglobin release. Circulating anti-GBM antibodies and renal biopsy with linear IgG and C3 deposits confirmed the diagnosis of anti-GBM disease. The possibility of anti-GBM must be considered in the differential diagnosis of acute renal failure in cocaine addicts. This unusual combination raises complex questions regarding the pathogenesis of this type of renal injury.

Pulmonary hemorrhage and antiglomerular basement membrane antibody-mediated glomerulonephritis after exposure to smoked cocaine (crack): a case report and review of the literature

A case of Goodpasture's syndrome with a negative immunofluorescence examination of the lung biopsy in a 32-year-old man is described. The patient was a 40 cigarettes per day smoker, who had been smoking cocaine (crack) up to 3 weeks before hospital admission. He developed a diffuse alveolar hemorrhage with extremely acute respiratory distress, followed by renal failure with anuria. Transjugular renal biopsy, immunofluorescence and serum antiglomerular basement membrane antibody titer studies confirmed the diagnosis of Goodpasture's syndrome without linear immunoglobulin G deposits as determined by immunofluorescence examination of the alveolar basement membranes. The case illustrates the potentially complex interrelations between an autoimmune disease and exposure to substances with possible antigenic properties, besides the imperative necessity for an early, accurate diagnosis and treatment for the potential for threatening life. Moreover, the association of Goodpasture's syndrome with crack has not been previously reported.

Goodpasture's syndrome. Unusual presentation after exposure to hard metal dust

An unusual case of Goodpasture's syndrome in a 26-year-old man with occupational exposure to hard metal dust is described. The patient developed a life-threatening interstitial lung disease that was followed by a rapidly progressive glomerulonephritis two months later. To our knowledge, association of Goodpasture's syndrome and hard metal exposure has not been reported previously.

Binding of anti-basement membrane antibody to alveolar basement membrane after intratracheal gasoline instillation in rabbits

A possible causal relationship has been suggested between hydrocarbon (gasoline, solvents, etc.) exposure and development of anti-basement membrane antibody-associated Goodpasture's syndrome in man. The authors evaluated the effect of hydrocarbons on pulmonary capillary permeability and binding of heterologous anti-basement membrane antibodies in the lungs after intratracheal instillation of minute amounts of unleaded gasoline into rabbits. The anti-glomerular basement membrane (GBM) antibodies used reacted with the alveolar basement membrane (ABM) in vitro by indirect immunofluorescence. The gasoline treatment altered pulmonary capillary permeability, judging from the increased accumulation of systemically administered radioiodinated bovine serum albumin in the alveolar and extravascular spaces of lungs; it also induced focal macroscopic and microscopic pulmonary histologic lesions. The gasoline caused focal in vivo binding of the anti-GBM antibodies to the ABM detectable by immunofluorescence microscopy. No binding was observed in lungs from control rabbits given saline instillations when assayed by immunofluorescence. The paired label radioisotope technique confirmed the increased antibody binding to lungs injured with gasoline (1.08 +/- 0.03 micrograms) versus 0.37 +/- 0.07 microgram after saline (P less than 0.001). These results indicate that gasoline exposure damages a pulmonary barrier that normally prevents binding of anti-GBM/ABM antibody to ABM and suggest that hydrocarbon exposure may be one of perhaps several pneumotoxic events that contribute to the episodic pulmonary hemorrhage in Goodpasture's syndrome by temporarily allowing ABM binding of anti-basement membrane antibodies.

Goodpasture's syndrome in a patient receiving penicillamine and carbimazole

A 51-year-old woman with advanced rheumatoid arthritis developed a Goodpasture's syndrome during treatment with penicillamine and carbimazole. Circulating antiglomerular basement membrane antibodies (anti-GBM) were present. Renal biopsy showed focal necrotizing glomerulonephritis with crescents, and HLA typing showed the presence of DR3 and DR4. The patient responded dramatically to pulse methylprednisolone and cyclophosphamide, with both clinical remission and disappearance of anti-GBM antibodies.

[D-penicillamine: mechanism of cellular action and induced autoimmune diseases]

The fall in the IgM rheumatoid factors under treatment is not sufficient to explain the effectiveness of D-penicillamine in rheumatoid arthritis. The mechanism of action of D-penicillamine is still poorly elucidated. In vitro, in the presence of copper ions, D-penicillamine inhibits the lymphoblastic transformation induced by polyclonal mitogens; it decreases the production of immunoglobulins by lymphocytes stimulated by the Pokeweed mitogen. This inhibitory action is exerced on the helper T lymphocytes via the production of hydrogen peroxide (H2O2). Monocytes are capable of blocking the inhibitory action of D-penicillamine. The mechanism of the auto-immune complications induced by D-penicillamine is controversial. Two theories have been proposed:--a modification of the auto-antigens due to the presence of the highly reactive thiol group;--an interference with the lymphoid cells involved in suppressor or effector lymphocyte cellular co-operation. These auto-immune complications can be classified into two groups: organ-specific diseases such as myasthenia, polymyositis, thyroiditis, and non organ-specific diseases such as Sjögren's syndrome and lupus. The suspension of D-penicillamine generally leads to the resolution of the symptoms, but corticosteroid and immunosuppressant treatment is sometimes required.

Remission of Goodpasture's syndrome after withdrawal of an unusual toxic

A 19 year old girl working as a hairdresser developed a severe anemia due to occult pulmonary hemorrhage followed by anti-GBM glomerulonephritis with normal renal function. Withdrawal of the suspected toxic factor, products used for permanent waving, was followed by both clinical remission and disappearance of linear deposits of immunoglobin from the renal glomeruli. Anti-GBM antibodies were only detected in the serum after clinical healing. In a case of mild Goodpasture, careful search for a toxin and its withdrawal may be the first therapeutic step.

Plasma exchange in the successful treatment of drug-induced renal disease

A 20-year-old girl with rheumatoid arthritis who has been treated with D-penicillamine for 7 months presented with fulminating Goodpasture's syndrome and a focal necrotising glomerulonephritis. A 35-year-old man who had been taking a low dose of phenytoin for epilepsy presented with nephrotic syndrome and a mesangiocapillary glomerulonephritis. CH50, C3 and C4 were low and a high level of immune complexes was detected. Both patients had severe lesions which were unlikely to recover on immunosuppression alone so were treated with intensive plasma exchange. 2 patients are described with serious drug-induced renal disease who recovered with intensive plasma exchange and immunosuppression.

Penicillamine-induced "Goodpasture's syndrome": successful treatment of a fulminant case

Goodpasture's syndrome is a recognised but rare complication of penicillamine therapy. Return of useful renal function has no been recorded with this complication. A patient is presented in whom aggressive management with plasmapheresis, haemodialysis and immunosuppression in the acute stage resulted in rapid control of pulmonary haemorrhage and return of useful renal function without the need for long-term haemodialysis. Immunofluorescence and electron microscopic studies of renal tissue together with the demonstration of circulating immune complexes, established the immune complex pathogenesis of this patient's disease. Microhaematuria is emphasised as an important warning sign of this complication.

Adverse reactions affecting the lung: possible association with D-penicillamine

Pulmonary hemorrhage and progressive renal failure in D-penicillamine-treated patients occurs rarely and does not fulfil the commonly used current criteria for Goodpasture's syndrome. Evidence suggests that the condition may develop as a result of drug-induced immune complex deposition. Histological and immunological information is too scanty to be certain whether pulmonary infiltrates occur in the absence of hemorrhage or whether they represent capillary damage of the same immunopathogenesis but of a milder form. Obliterative broncho-bronchiolitis has been seen in some patients who have never received penicillamine so that a cause and effect relationship has not been established.

D-Penicillamine-induced Goodpasture's-like syndrome in primary biliary cirrhosis--successful treatment with plasmapheresis and immunosuppressives

A 36-yr-old woman with primary biliary cirrhosis developed a Goodpasture's-like syndrome while on D-penicillamine treatment. She responded dramatically to plasmapheresis and immunosuppressive agents. Her illness was felt to be induced by D-penicillamine. This case illustrates the potential toxicity of D-penicillamine in primary biliary cirrhosis. We suggest that this drug be used only in controlled trials until efficacy is demonstrated.

Penicillamine in rheumatoid arthritis: adverse effects

The use of penicillamine in rheumatoid arthritis (RA) is limited by the incidence of adverse effects, some of which are potentially hazardous. However, adverse effects are dose-related and the advantages and disadvantages of different fixed and flexible dose regimes are discussed. The incidence of adverse effects is significantly greater in patients previously treated with gold who developed toxicity to that drug--no such increase being found in gold treated patients whose only reason for stopping gold was ineffectiveness. Rashes which develop after several months of treatment are variants of pemphigus and their various presentations are described. Fatal reactions, fortunately rare, are predominantly associated with aplasia of the bone marrow. Monthly haematological checks coupled with meticulous charting of the results may reveal trends as well as numerical changes and serve as an early warning of marrow damage.

D-penicillamine induced Goodpasture's syndrome in Wilson's disease

Fatal pulmonary hemorrhages and rapidly progressive glomerulonephritis occurred in three patients with Wilson's disease (hepatolenticular degeneration) who had been treated with penicillamine for 2 to 31/2 years. Light microscopic studies of the kidneys showed severe glomerulonephritis with crescent formation, and the lungs showed intraalveolar hemorrhages. Although the clinical and pathologic abnormalities were those of Goodpasture's syndrome, immunofluorescence microscopic studies in the one case tested showed an interrupted, rather than linear, fluorescence pattern.