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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 2  |  Page : 394-397
Chronic tubulo-interstitial nephritis in common variable immunodeficiency: A rare association


1 Department of Pediatrics, Institute of Post Graduate Medical Education and Research, Kolkata, India
2 Department of Rheumatology, Institute of Post Graduate Medical Education and Research, Kolkata, India

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Date of Web Publication11-Mar-2014
 

   Abstract 

Common variable immunodeficiency (CVID) is characterized by reduced serum immunoglobulin levels and repeated serious bacterial infections involving different organ systems. Chronic kidney disease (CKD) is an uncommon association with CVID. Chronic tubulo-interstitial nephritis in a case of CVID that progressed to CKD is distinctly rare.

How to cite this article:
Sarkar S, Mondal R, Nandi M, Ghosh P. Chronic tubulo-interstitial nephritis in common variable immunodeficiency: A rare association. Saudi J Kidney Dis Transpl 2014;25:394-7

How to cite this URL:
Sarkar S, Mondal R, Nandi M, Ghosh P. Chronic tubulo-interstitial nephritis in common variable immunodeficiency: A rare association. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Nov 15];25:394-7. Available from: http://www.sjkdt.org/text.asp?2014/25/2/394/128582

   Introduction Top


Common variable immunodeficiency (CVID) is the most common cause of primary hypo­gammaglobulinemia. This is characterized by reduced serum immunoglobulin (Ig) levels, re­peated infections and association with various autoimmune and granulomatous diseases. We report a case of CVID that was complicated with chronic kidney disease (CKD) due to chro­nic tubulo-interstitial nephritis.


   Case Report Top


An 8-year-old girl, born out of non-consan­guineous marriage, presented with respiratory distress for one day following fever and cough for two weeks. She had a history of several episodes of similar serious chest infections since infancy and required hospital admissions earlier on two occasions. On those occasions, the patient received azithromycin once for five days, and on the second admission she re­ceived cefixime for five days. She had not taken any other drug for some time prior to the current presentation.

She was born by cesarean section at full-term. Her birth weight was 3.2 kg. The mo­ther's antenatal, natal and post-natal periods were uneventful. The child's developmental history was normal. Immunization was com­plete as per the national immunization sche­dule.

She developed progressive loss of scalp and body hair, resulting in total loss of hair at around four years of age. There was no history of similar illness in the family. The other sib­ling, her elder sister, was 17 years of age and was normal. On examination, she was alert and cooperative. Her height was 122.5 cm (75 th percentile, CDC) and weight was 17 kg (below 5 th percentile, CDC). Her respiratory rate was 50/min. Other vital parameters, inclu­ding blood pressure, were normal. Her scalp and body hair were absent. She had gene­ralized skin pigmentation, dystrophic nails and loss of enamel of the teeth. Examination of the chest revealed bilateral coarse crepitations and polyphonic wheeze. Her abdomen was soft with 4 cm hepatomegaly. The spleen was just palpable. Lymph nodes were not significantly enlarged. The urine output was normal.

On investigations, the hemoglobin level was 8.5 g/dL, total leukocyte count was 8300/mm 3 (neutrophils 60%, lymphocytes 32%, eosino­phils 5%, monocyte 3%) and platelet count was 1.83 lakhs/mm 3 . Liver function tests were normal. The blood urea level was 32 mg/dL and serum creatinine was 0.7 mg/dL. Chest X-ray showed accentuation of bronchovascular markings with bilateral hilar congestion. Rou­tine examination of the urine showed 20-30 pus cells per high-power field. No red blood cells or epithelial cells were seen. There were no casts in the urine. Albumin was trace and no glucose or ketone body was found. Urine culture and sensitivity showed significant growth of E. coli. She responded to intra­venous ofloxacin for 14 days given according to the sensitivity report. Ultrasonography (USG) of the abdomen, performed after two weeks, was normal. The size of the left kidney was 8.2 cm and that of the right kidney was 8.3 cm. In view of recurrent sino-pulmonary and urinary tract infections with alopecia totalis, she underwent investigations for immu­nodeficiency.

Immunoglobulin assay showed pan-hypo-gammaglobulinemia. IgG: 347 mg/dL (normal 572-1474 mg/dL), IgA: <4 mg/dL (normal 34-305 mg/dL), IgM: 11 mg/dL (normal 31-208 mg/dL) and IgE: 0.38 IU/mL (normal up to 90 IU/mL). The lymphocyte count including T and B cell subsets was normal on flow cyto­metry. Complement assay revealed C 3 level of 134.4 mg/dL (normal 90-180 mg/dL) and C 4 level of 85.6 mg/dL (normal 10-40 mg/dL). Nitroblue tetrazolium test for phagocytic acti­vity was normal. Anti-nuclear factor and dsDNA were negative. Screening for human immunodeficiency virus and hepatitis B sur­face antigen was negative.

History of recurrent serious infections, alo­pecia, pan-hypo-gammaglobulinemia with normal T cell count, normal phagocytic function and absence of hypo-complementemia esta­blished the diagnosis of CVID.

She was readmitted five months later with fever and pneumonia. There was no history of rash or joint pain. The chest X-ray showed bilateral patchy pneumonitis. She was treated with intravenous cefuroxime for 10 days. Urine analysis showed three to four pus cells and four to five red blood cells per high-power field and no eosinophils. Albumin was 1+ and a few granular casts and phosphate crystals were seen. No ketonuria or glycosuria was noted. Other investigations were insignificant but her blood urea level was 112 mg/dL and serum creatinine level was 1.5 mg/dL. USG abdomen showed bilateral early renal paren­chymal disease. The size of the left kidney was 7.7 cm and that of the right kidney was 7.6 cm. The pelvicalyceal system and urinary bladder were normal. Her estimated glomerular filt­ration rate (eGFR) at that time was 44.73 mL/1.73 m 2 /min. Because renal complications are very rare in patients with CVID, we per­formed a renal biopsy. While the biopsy report was awaited, her serum creatinine level rose to 4.5 mg/dL. She was put on intermittent peri­toneal dialysis. Her eGFR at the time of star­ting dialysis was 14.9 mL/1.73 m 2 /min. The serum creatinine level was still rising, and went to 10.11 mg/dL, potassium level was 6.2 mEq/L and serum calcium level was 9.28 mg/ dL. Her eGFR dropped to 6.66 mL/1.73 m 2 / min. She was then put on continuous ambu­latory peritoneal dialysis.

Her renal biopsy report showed presence of marked tubular degeneration, interstitial fibro­sis, tubular loss and presence of more than 50% atrophic tubules along with dense depo­sits of mixed inflammatory infiltrations with predominant lymphomononuclear cells in the interstitium. Changes in the glomeruli were non-specific. Blood vessels were unremar­kable. A direct immunofluorescence study did not reveal any deposits. Congo red staining for amyloidosis was negative. The impression on renal biopsy was chronic tubulo-interstitial nephritis, and was the cause of CKD in our patient. She is currently enlisted for renal transplantation.


   Discussion Top


CVID is characterized by hypo-gammaglobulinemia, repeated respiratory infections, chro­nic gastrointestinal symptoms, malabsorption, arthritis and multisystem involvement. Although reduction of IgG and IgA are characteristic features, approximately 50% of patients with the deficiency also have diminished IgM levels and T-lymphocyte dysfunction. [1] Apart from infections, there is also an increased incidence of malignancy and granulomatous and auto­immune diseases like juvenile rheumatoid arthritis, systemic lupus erythematosus and Sjogren's syndrome. [2]

All types of Igs were reduced in our patient. Her T cell count was normal, with no signifi­cant alteration of CD4 and CD8 ratio. The high C 4 level seen is explained by association of infection. She had repeated respiratory and urinary infections that required hospitalization. Alopecia universalis is also an associated fea­ture in CVID. [3] Recurrent serious infections, alopecia and pan-hypo-gammaglobulinemia favor the diagnosis of CVID in our patient. Other possibilities of primary immunodefi­ciency like T-cell defect, phagocytic defect or hypo-complementemia were excluded.

The association of renal disease with CVID is distinctly uncommon. There are reports of re­nal granulomatous disease in association with CVID. [4] One patient had interstitial non-caseating granuloma and immunoglobulin (IgM)-complex glomerulonephritis with a membranoproliferative pattern. [5] Another patient had non-caseating renal granuloma in association with hypercalcemia. [6] Steroid-sensitive nephrotic syndrome has also been reported. [7] In one report, a patient having selective IgG deficiency developed end-stage kidney disease (ESKD) due to chronic interstitial nephritis and early membranous nephropathy. [8] A 15-year-old girl who developed ESKD and underwent renal transplantation was subsequently diagnosed to have CVID. [9]

The literature review from India has shown one study of CVID that described 23 patients; most of them were children. [10] None of the children had renal involvement. In our pa­tient, although there were several episodes of sino-pulmonary infections, only one episode of urinary tract infection had occurred. The his­tory, clinical features and investigations did not suggest recurrent pyelonephritis as a pos­sible etiology of CKD or ESKD. Also, there was no obvious suggestion of the renal disease being caused by any drugs or obstructive neph­ropathy. Association with auto-immune or gra­nulomatous disease also was not found. Our patient with CVID developed chronic tubulo-interstitial disease that progressed to CKD, and even further to ESKD requiring renal trans­plant. Immunological abnormality of CVID may, in part or whole, be responsible for this rare association with chronic tubulo-interstitial disease.

CKD associated with CVID in a pediatric patient is rarely reported in the literature. Chronic tubulo-interstitial disease as a cause of CKD in a case of CVID is even rarer.

Funding: None.

Conflict of interest: None.

 
   References Top

1.Cunningham-Rundles C. Autoimmune mani­festations in common variable immunode­ficiency. J Clin Immunol 2008;28 Suppl 1: S42-5.  Back to cited text no. 1
[PUBMED]    
2.Mihola D, Frint B, Balogh Z. Erosive poly­arthritis in a patient with a gammaglobulinaemia. Primary immunodeficiency diseases with rheumatic manifestations. Qrv Hetil 2003; 28:919-24.  Back to cited text no. 2
    
3.Boonyaleepun S, Boonyaleepun C, Schlactus JL. Effect of IVIG on the hair regrowth in a common variable immune deficiency patient with alopecia universalis. Asian Pac J Allergy Immunol 1999;17:59-62.  Back to cited text no. 3
    
4.Fakhouri F, Robino C, Lemaire M, et al. Granulomatous renal disease in a patient with common variable immunodeficiency. Am J Kidney Dis 2001;38:E7.  Back to cited text no. 4
    
5.Benoit G, LapeyraquelAL, Sartelet H, Saint-Cyr C, Le Deist F, Haddad E. Renal granuloma and immunoglobulin M-complex glomerulo­nephritis: A case of common variable immuno­deficiency. Pediatr Nephrol 2009;24:601-4.  Back to cited text no. 5
    
6.Meyer A, Lachmann HJ, Webster AD, Burns A, Thway K. Hypercalcemia in a patient with common variable immunodeficiency and renal granulomas. Am J Kidney Dis 2005;45:e90-3.  Back to cited text no. 6
    
7.Garimella-Krovi S, Panner BJ, Springate JE. Renal Disease in Common Variable Immuno­deficiency-Case Report and Literature Review. Pediatr Asthma Allergy Immunol 2008;21:35-9.  Back to cited text no. 7
    
8.Leung TF, Li CK, Shing MM, Chik KW, Yuen PM. Three children with failure to thrive and recurrent infections. HK J Paediatr 2000;5:48-51.  Back to cited text no. 8
    
9.Hogan MB, Wilson NW, Muchant DG. Renal transplantation in a patient with common variable immunodeficiency. Am J Kidney Dis 1999,33:E7.  Back to cited text no. 9
    
10.Dutta U, Kaur KJ, Kumar L, et al. Immuno­globulin deficiency. Indian Pedtrics 1993;30: 461-7.  Back to cited text no. 10
    

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Correspondence Address:
Sumantra Sarkar
Department of Pediatrics, Institute of Post Graduate Medical Education and Research, Kolkata
India
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DOI: 10.4103/1319-2442.128582

PMID: 24626011

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    Abstract
   Introduction
   Case Report
   Discussion
    References
 

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