Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2019  |  Volume : 30  |  Issue : 1  |  Page : 258--260

Widening spectrum of renal involvement in psoriasis: First reported case of C3 glomerulonephritis in a psoriatic patient


Manish R Balwani1, Amit Pasari1, Priyanka Tolani2,  
1 Department of Nephrology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Medicine, Northern Railway Central Hospital, New Delhi, India

Correspondence Address:
Manish R Balwani
Department of Nephrology, Jawaharlal Nehru Medical College, Sawangi, Wardha - 440 001, Maharashtra
India

Abstract

Renal involvement in psoriasis is usually seen as mesangioproliferative glomerulonephritis (GN), IgA nephropathy, and focal segmental glomerulosclerosis. Microscopic hematuria is not uncommon in a patient of psoriasis with above-mentioned disorders. We found C3 GN as a cause when evaluated for macroscopic and persistent microscopic hematuria in a patient of psoriasis.



How to cite this article:
Balwani MR, Pasari A, Tolani P. Widening spectrum of renal involvement in psoriasis: First reported case of C3 glomerulonephritis in a psoriatic patient.Saudi J Kidney Dis Transpl 2019;30:258-260


How to cite this URL:
Balwani MR, Pasari A, Tolani P. Widening spectrum of renal involvement in psoriasis: First reported case of C3 glomerulonephritis in a psoriatic patient. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Jun 17 ];30:258-260
Available from: http://www.sjkdt.org/text.asp?2019/30/1/258/252922


Full Text



 Introduction



Psoriasis is a chronic immune-mediated inflammatory skin disorder. Renal involvement in association with psoriasis is being increasingly reported nowadays. C3 glomerulopathy refers to aberrant alternative pathway activation leading to predominant C3 accumulation within the glomerulus. We came across a case of C3 glomerulopathy in a psoriatic patient when evaluated for hematuria.

 Case Report



A 28-year-old male came to consult for persistent microscopic hematuria for the past four months. The patient was a diagnosed case of psoriasis since five years which was controlled with methotrexate 15 mg once weekly. The patient gave a history of gross hematuria around three months back, for which he was treated at nearby hospital with intravenous antibiotics suspecting cystitis. At that time, the patient gave no history of the passage of clots, burning urination, hesitancy or precipitancy of urination. Afterwards, the patient was examined regularly by nearby physician and every time doctor found that patient had persistent microscopic hematuria, for which he came to consult us. There was no history of oliguria, pedal edema, facial puffiness, rash, joint pain, fever, sore throat, or recent vaccination. On examination, the patient was conscious, oriented, and normotensive. His blood pressure was 110/80 mm Hg. He had widespread skin lesions distributed over both upper and lower extremities as well as on the trunk. Skin lesions were typically scaly dry. Examination of all other systems revealed no abnormality. His peripheral blood picture revealed Hb 14.7 g%, total lymphocyte count 7200/mm3 with neutrophil 68%, lymphocyte 28%, monocyte 1%, eosinophil 3%, and erythrocyte sedimentation rate 18 mm at the end of 1 h. Blood urea and serum creatinine levels were 12 mg% and 0.95 mg%, respectively. Serum protein was 6.8 g%, albumin 3.8 g%, and globulin 3.0 g%. Serum cholesterol level was 152 mg%. Urine examination revealed pH 6.4, albumin trace, red blood cells (RBC) +++, pus cells 2-3/HPF, sugar-nil, granular casts-absent. 24 h urinary protein excretion was 273 mg. antistreptolysin O titer was not raised (152 U/mL). Urine for dysmorphic RBC was positive (48%). Ultra-sonography showed normal size kidneys with maintained cortical medullary differentiation. Serum antinuclear antibody by intrinsic factor came to be negative. Coagulation profile was normal. In view of persistent microscopic hematuria and probable glomerular etiology, the patient was advised for renal biopsy. Our provisional diagnosis was IgA nephropathy. However, kidney biopsy revealed mesangial and focal endocapillary proliferative glomerulopathy with fibrocellular crescents in three of 40 sampled glomeruli. The immunofluroscent study revealed dominant mesangial and capillary wall staining for C3 with no staining for IgG, IgM, IgA, C1q, Kappa, and lambda light chains. Electron microscopy revealed glomerular basement thickness varying from 263.1- to 519.8-nm thickness ruling out thin basement membrane disease. It also showed subendothelial, intra-membranous and mesangial electron dense deposits [Figure 1]. Thus, confirming a diagnosis of C3 glomerulonephritis (GN). After-ward, serum complement levels were sent and the level of both C3 and C4 came to be normal. The patient was started on mycophenolate mofetil 500 mg thrice a day. After starting therapy, in the past six months, there has been no episode of gross hematuria and patient has been doing well.{Figure 1}

 Discussion



Renal involvement in psoriasis has been increasingly reported in the last few years. IgA nephropathy has been the most common finding in renal biopsy specimens (as a mesangioproliferative type) in psoriatic patients. AA amyloidosis, membranous nephropathy, and focal proliferative glomerulopathy are also reported to occur in psoriatic patients.[1],[2],[3] Drug-related kidney dysfunction should always be kept in mind while evaluating kidney dysfunction in such patients as there is frequent use of nonsteroidal anti-inflammatory drugs for joint pain control. Clinical presentation of C3 glomerulopathy is variable, but the majority of patients have slowly progressive course with renal survival of approximately 50% over 10 years.[4]

Our patient had mesangial and focal endocapillary proliferative GN with electron dense C3 deposits in the mesangium, intramem-branous and subendothelium. This is probably the first reported case of biopsy-proven C3 GN in a psoriatic patient which might unlink the possible association of a common dysregulated immune pathway. Probably, the uncontrolled inflammatory process of psoriatic arthritis would have lead to dysregulated alternative pathway activation. Our patient responded well to mycophenolate mofetil 500 mg thrice a day. Patients skin lesions also improved with the addition of mycophenolate therapy. More frequent biopsies in such different patients might reveal further details in the future. Authors strongly recommend the use of electron microscopic evaluation whenever a biopsy is performed in a psoriatic patient to evaluate microscopic hematuria.

 Conclusion



Renal involvement in psoriatic patients is being commonly seen nowadays. Routine urinalysis and kidney function assessment might help in early detection of renal involvement in such patients. Wider use of renal biopsy with frequent use of electron microscopic examination might help in early diagnosis of sub-clinical or overt nephropathy. This is probably the first reported case of C3 GN in a psoriatic patient where skin lesions, as well as renal manifestations, were controlled with mycophenolate therapy. This case report may be a mere coexistence or may be pointing toward some common immunological etiology which needs to be further evaluated.

Conflict of interest:

None declared.

References

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