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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 : 5  |  Page : 1065-1067
Renal paraneoplastic vasculitis complicating lung adenocarcinoma


1 Internal Medicine Department, Habib Thameur Hospital, Tunis, Tunisia
2 Nephrology Department, La Rabta Hospital, Tunis, Tunisia

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Date of Web Publication2-Sep-2014
 

   Abstract 

Renal paraneoplastic vasculitis (RNPV) is rare. It can be revealed by glomerulonephritis, microaneurysms or renal failure. RPNV may precede the onset of the primary tumor, and treatment and prognosis depend on the etiology (primary tumor). A 54-year-old man who had a primary lung adenocarcinoma was admitted for nephrotic syndrome. The investigations revealed RNPV. The patient was treated with corticosteroids at high dose and cyclophosphamide with improvement of the renal condition; however, the patient died from worsening of his pulmonary neoplasia.

How to cite this article:
Dhaou BB, Boussema F, Aydi Z, Ketari S, Baili L, Moussa FB, Rokbani L. Renal paraneoplastic vasculitis complicating lung adenocarcinoma. Saudi J Kidney Dis Transpl 2014;25:1065-7

How to cite this URL:
Dhaou BB, Boussema F, Aydi Z, Ketari S, Baili L, Moussa FB, Rokbani L. Renal paraneoplastic vasculitis complicating lung adenocarcinoma. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Mar 18];25:1065-7. Available from: http://www.sjkdt.org/text.asp?2014/25/5/1065/139942

   Introduction Top


Renal paraneoplastic vasculitis (RNPV) is rare and can present as glomerulonephritis, microaneurysms or renal failure. [1],[2],[3] Treatment and prognosis depend on the etiology (primary tu­mor). Eradication of the initial tumor can result in the disappearance of PNRV. The PNRV may precede the onset of the primary tumor. Malignant tumors involved are often hematologic or solid tumor type carcinoma: Renal, pulmonary or digestive.

We present a case of RNPV in a patient with primary pulmonary adenocarcinoma.


   Case Report Top


A 54-year-old man, who had been followed-up in the respiratory clinic for chronic bron­chitis had a chest X-ray that revealed the pre­sence of a left pedicle opacity in February 2008 [Figure 1]. Chest computed tomography (CT) showed a left proximal bipolar tissue mass with mediastinal encroachment associa­ted with bilateral pulmonary nodules [Figure 2]. The bronchoscopy showed a bud of the left main bronchus with pathologic examination that confirmed the diagnosis of a non-micro-cellular carcinoma.
Figure 1: Chest CT: Soft tissue mass in the left proximal pole with mediastinal encroachment.

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Figure 2: Renal biopsy: Masson's trichrome staining: Presence of an extracapillary proliferation and a necrotic lesion.

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On March 3, 2008, he was hospitalized in the emergency general surgery service for acute intestinal obstruction and he underwent small intestine resection. The histological study con­cluded that ischemic necrosis of the small intes­tine was of mechanical origin. One month later, he was admitted for exploration of leg edema lasting for 10 days, with an abdominal bloating and discovery of proteinuria and hematuria with urinary strips. Physical examination dis­closed the presence of ascites and symmetrical edema of the lower limbs. Laboratory investi­gations showed proteinuria: 16 g/24 h, serum albumin: 11.9 g/L, serum creatinine:137 μmol/ L and clearance creatinine at 54 mL/min. The ESR was 90 mm at the first hour, C-reactive protein was 42 mg/L, fibrinogen was 7.6 g/L and hemoglobin was 9 g/dL. The immuno-logical investigations (antinuclear antibodies, antineutrophil cytoplasmic antibodies, cryo­globulins and circulating immune complexes) and tumor markers (PSA, CEA, CA 19.9, αFP) were negative. Kidney biopsy revealed the presence of necrotic lesions affecting at least six glomeruli, with extra-capillary proliferation in the form of circumferential cellular cre­scents at two glomeruli and segmental prolife­ration in the others without breaking the cap­sules. The podocytes were highly turgid and vacuolated and a glomerulus had segmental and endo-membranous deposits. Fibrosis was evident in the interstitium, with small inflam­matory infiltrates of polymorphic cells with sometimes picnotic nuclei besides moderate fibrous endarteritis affecting medium-caliber vessels and inflammatory infiltrate around the veins. On the immunofluorescence, there were segmental deposits of anti-IgM and C3 and vascular deposits of C3 and fibrinogen. Focal segmental glomerulonephritis necrotizing with pauci-immune crescents evoking renal vas­culitis was diagnosed from the findings of the biopsy [Figure 3] and [Figure 4]. RNPV was diagnosed in the context of the nephrotic syndrome, lung adenocarcinoma and focal segmental necro­tizing glomerulonephritis, suggesting vasculitis. The patient was treated with three i.v. doses of 1 g methyl prednisolone and 1 mg/kg/day oral corticosteroids, and six courses of cyclophosphamide twice a month (500 mg per course). The response of the patient was marked by an improved renal status (disappea­rance of edema, proteinuria = 1.6 g/24 h and disappearance of the inflammatory syndrome). However, there was an increase in the size of the mediastinal-pulmonary mass and appea­rance of a left metastatic pleural effusion [Figure 5], which drained several times but could not prevent the patient's fatal outcome.
Figure 3: Renal biopsy: Hematoxylin eosin staining: The presence of small crescent segmental and segmental necrotic lesions.

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Figure 4: Chest X-ray: Left abundant pleural effusion.

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Figure 5: Chest CT: Mediastino-pulmonary left mass and left pleural effusion.

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   Discussion Top


RNPV related to solid tumors can result in different manifestations depending on the type and location of the initial tumor: Fever (41.7%), cutaneous signs (78.3%), arthralgia (46.7%), peripheral neuropathy (31.7%), renal events (23.3%) and the presence of antibodies ANCA (20.4%). [1]

RNPV can present as glomerulonephritis (11.7%), micro-aneurysms (11.7%) or renal failure (6.7%). [1] The association of lung cancer with the nephrotic syndrome was reported in 1-3% of the cases. [2] This is most often an extramembranous glomerulonephritis, but in our case, the patient had focal segmental necrotizing glomerulonephritis suggestive of vasculitis. Lung adenocarcinoma is more com­monly associated with RNPV than other histolo-gical types. [3]

The curative treatment of the primary tumor (surgery, chemotherapy, radiotherapy) is effec­tive in the cure of RNPV. If the primary tumor is not curable, the treatment of vasculitis is based on corticosteroids alone or in combi­nation with immunosuppressive drugs. [1] Para-neoplastic vasculitis is usually curable in 65% of cases, but recurrence occurs in 33.3%. [1] Recurrence or new onset of renal paraneo-plastic vasculitis is associated with recurrence of the tumor (55%) or its extension (metas-tasis). [4] For our patient, the treatment was only palliative because the tumor was in an advanced stage.

 
   References Top

1.Solans-Laqué R, Bosch-Gil JA, Pérez-Bocanegra C, Selva-O'Callaghan A, Simeón-Aznar CP, Vilardell-Tarres M. Paraneoplastic vasculitis in patients with solids tumors: Report of 15 cases. J Rheumatol 2008;35:294-304.  Back to cited text no. 1
    
2.Fain O, Hamidou M, Cacoub P, et al. Vasculitis associated with malignancies: Analysis of sixty patients. Arthritis Rheum 2007;57:1473-80.  Back to cited text no. 2
    
3.Yangui I, Msaad S, Smaoui M, et al. Small-cell lung cancer and rapidly fatal nephritic syndrome. Rev Pneumol Clin 2007;63:331-4.  Back to cited text no. 3
    
4.Cosar-Alas R, Yurut-Caloglu V, Karagol H, et al. Paraneoplastic syndrome of non-small cell lung carcinoma: A case with pancytopenia, leuco-cytoclasic vasculitis and hyperthrophic osteo-arthropathy. Lung Cancer 2007;56:455-8.  Back to cited text no. 4
    

Top
Correspondence Address:
Dr. Besma Ben Dhaou
Internal Medicine Department, Habib Thameur Hospital, Tunis
Tunisia
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DOI: 10.4103/1319-2442.139942

PMID: 25193910

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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    Abstract
   Introduction
   Case Report
   Discussion
    References
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