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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 3  |  Page : 386-389
Acute Tubulointerstitial Nephritis and Anterior Uveitis (TINU Syndrome): A Report of Two Cases


1 Department of Nephrology and Hemodialysis, Ibn Rochd University Hospital, Casablanca, Morocco
2 Department of Pathology and Anatomy, Ibn Rochd University Hospital, Casablanca, Morocco

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   Abstract 

TINU or Dobrin syndrome is a rare oculo-renal inflammatory condition which is comprised of acute idiopathic tubulointerstitial nephritis and uveitis. We report here two female patients aged 35 and 44 years, who were admitted with severe renal failure of acute onset (serum creatinine of 607 and 310 Umol/L [Editor note: do you mean "µmol/L"?] respectively) with the first patient requiring hemodialysis. The cause of acute renal failure was unclear on clinical and laboratory assessment, and a percutaneous renal biopsy was performed which showed features of acute tubulointerstitial nephritis in both cases. Both patients were started on oral steroids at a dose of 1 mg/kg/day. There was progressive improvement of their renal function. Three months later, the two patients presented with bilateral anterior uveitis requiring local corticosteroid therapy. This was followed by total resolution of the uveitis. The cause of the interstitial nephritis and the uveitis could not be identified in the two cases. The renal function was normal in these patients after 24 and 27 months of follow-up, respectively. Dobrin or TINU syndrome is rare, and must be considered in patients who present with acute tubular interstitial [Editor note: for consistency with the title, you may wish to replace this with "tubulointerstitial"] nephritis and anterior uveitis.

How to cite this article:
Mortajil F, Rezki H, Hachim K, Zahiri K, Ramdani B, Zaid D, Skalli S. Acute Tubulointerstitial Nephritis and Anterior Uveitis (TINU Syndrome): A Report of Two Cases. Saudi J Kidney Dis Transpl 2006;17:386-9

How to cite this URL:
Mortajil F, Rezki H, Hachim K, Zahiri K, Ramdani B, Zaid D, Skalli S. Acute Tubulointerstitial Nephritis and Anterior Uveitis (TINU Syndrome): A Report of Two Cases. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2021 Mar 6];17:386-9. Available from: https://www.sjkdt.org/text.asp?2006/17/3/386/35772

   Introduction Top


TINU Syndrome is a rare oculo-renal inflammatory condition (less than 56 cases have been described), which is comprised of acute tubulointerstitial nephritis (ATIN) and uveitis. This syndrome occurs in young adults, mainly females. It is idiopathic and is characterized by a benign course. The nephropathy disappears even without treatment, whereas the uveitis tends to recur in some patients.


   Case Reports Top


Case 1

FL, a 35-year-old female patient, was admitted to the nephrology department on the December 13, 2001 with features of non-oliguric acute renal failure (ARF). She had undergone appendicectomy in 1984, she had pulmonary tuberculosis which was treated for nine months in 1988, and she underwent a cesarean section in 1998. A month before her present ailment, she had bilious vomiting, diffuse arthralgia, and loss of weight (10 kg in two months). The clinical examination was normal except for mild dehydration. Urine examination showed +2 proteinuria. Laboratory assessment showed the following: serum creatinine, 607 µmol/L, blood urea nitrogen, 22.4 mmol/L; proteinuria of 0.38 g/24 hours; serum calcium, 8.75 mg/dL; serum total protein, 82 g/L; alkaline phosphatase, 272 IU/L; a normal hemogram; an elevated erythrocyte sedi­mentation rate of 90 mm at the first hour; hypergammaglobulinemia on protein electro­phoresis; negative Bence Jones proteinuria; and leukocyturia of 70.000 cells/ml on cyto­bacteriologic examination of the urine. Detailed immunologic assessment was negative [Anti­nuclear anti-body (ANA), anti-DNA antibody (DNAAb), rheumatoid factor (RF), VDRL, hepatitis B surface antigen (HbsAg), and anti hepatitis C antibody (HCVAb). Renal ultrasound showed well-differentiated kidneys of normal size. A percutaneous renal biopsy was performed because of the lack of improve­ment of the renal function after rehydratation, and it showed features of tubulointerstitial lesions with no glomerular or vascular lesions and the absence of immunoglobulin or com­plement deposits on immunofluorescence [Figure - 1],[Figure - 2]. The patient was given prednisone at a dose of 1 mg/kg/day after adequate rehydration. The course was marked by a progressive improvement of the renal function. Three months later, she presented with painful red eyes and ophthalmological examination was suggestive of bilateral granulomatous anterior uveitis. She responded favorably to local application of mydriatics and cortico­steroids. Both eyes, as well as renal function, were normal after two years of follow-up.

Case 2

RF, a 40-year-old female, was admitted on February 5, 2003 [Editor note: although the existing date format was correct, this date was changed to be consistent with the date in the previous case] with ARF. Past history revealed primary sterility for eight years and that one paternal aunt had died of chronic renal failure. Two months before her admission, she had post prandial vomiting with epigastric discomfort, right rib pain, and loss of weight (13 kg in 2 months). The physical examination at admission was normal. Urine analysis showed ++ [Editor note: do you mean "2+"?] proteinuria. Laboratory assessment showed the following: serum creatinine, 300 µmol/L, blood urea nitrogen, 5.7 mmol/L; proteinuria of 0.68 g/24 hours; calcium, 11.3 mg/dL; serum total protein, 88 g/L; alkaline phosphatase, 272 IU/L; normal hemogram; an elevated erythrocyte sedimentation ratio of 84 mm at the first hour; hyper-gamma globulinemia of 23.2 g/ L on protein electrophoresis; and negative Bence Jones proteinuria. Serum protein immunoelectrophoresis showed moderate increase of IgG, IgA, and IgM without any qualitative anomalies of light chains. Detailed immunological assessment was negative (ANAb, DNAAb, RF, HbsAg, and HVCAb). Renal ultrasound and X-ray of the chest were normal. Percutaneous renal biopsy showed the presence of tubulointer­stitial lesions with normal glomeruli and blood vessels, while immunofluorescence was negative for any deposits. Treatment with oral prednisone at a dose of 1mg/kg/day was started. The evolution was marked by a progressive amelioration of the renal dysfunction. A month later, she developed a decrease in vision in both eyes (4/10 right eye, 8/10 left eye), and bilateral granulomatous anterior uveitis was diagnosed. The etiologic assess­ment of the uveitis was negative; progressive improvement was seen with local steroid therapy. Both ophthalmological examination and renal function were normal after 27 months of follow-up.


   Discussion Top


TINU syndrome is a rare oculo-renal inflammatory condition [1] which is comprised of idiopathic acute tubulointerstitial nephritis and uveitis. The first cases were described in 1975 by Dobrin, who gave his name to this syndrome. [1] This syndrome occurs in young adults, mainly females. [2] The clinical mani­festations are stereotyped with alterations in the general condition of the patient and weakness. [3],[4] The renal involvement is mani­fested by ARF, moderate proteinuria, and leukocyturia, sometimes by normoglycemic glycosuria, and less frequently by micro­scopic hematuria with an accelerated sedi­mentation rate and hypergammaglobu­linemia. [4],[5] Renal biopsy shows acute tubulointerstitial nephritis with edema and diffuse cellular infiltrates composed of lymphocytes, plasmacytes, eosinophils, and rarely, giant cells or epithelioid cells. The glomeruli are normal and immunofluorescence is negative. [4],[5],[6] The ocular involvement occurs after renal involvement. It can be asymptomatic or manifest in the form of uveitis with ciliar injection (redness and dilated vessels) in the corneal lamina, myositis, and ocular pain. Visual acuity is generally pre­served. Examination with a slit lamp confirms the diagnosis of anterior uveitis. [7] Some differential diagnoses, such as systemic diseases with accompanying uveitis (spondyloathro­pathies, Behcet's and Rieter's disease, sarcoi­dosis, juvenile rheumatoid arthritis, and Sjorgen's syndrome) and infections (toxo­plasmosis, cytomegalovirus, and herpetic virus) must be excluded before arriving at a diagnosis of TINU syndrome.

The course and prognosis of TINU syndrome are favorable, even without treatment. Renal recovery occurs either spontaneously or after steroid therapy. [4],[7] Uveitis responds favorably to local steroids as well as non-steroidal anti­inflammatory drugs. It is characterized by a tendency to recur, which is not the case with the renal disease. Hence, there may be a necessity for prolonged therapy with cortico­steroids even after recovery as well as long­ term follow-up of all cases of TINU syndrome. Also, it is essential to look for uveitis in all cases of idiopathic acute tubulointerstitial nephritis.

 
   References Top

1.Robin RS, Verner RL, Fish AL. Acute eosinophilic interstitial nephritis and renal failure with bone marrow-lymph node granulomas and anterior uveite. A new syndrome. Am J Med 1975;59:325-33.  Back to cited text no. 1    
2.Rodriguez-Perez JC, Cruz-Alamo M, Perez­Aciego P, et al. Clinical and immune aspects of idiopatic acute tubulointerstitial nephritis, and uveitis symdrome. Am J Nephrol 1995;15:386-91.  Back to cited text no. 2  [PUBMED]  
3.Guedira K, Boutimzine N, Karib H, et al. Bilateral anterior uveitis and acute tubulointerstitial nephritis (TINU Syndrome). A case report. J Fr ophtalmol 2000;23:708-10.  Back to cited text no. 3    
4.Gallego N, Estepa R, Mampaso F, et al. Tubulointerstital nephretis and asymptomatic uveitis. J Nephrol 2000;13: 373-6.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Ivanyi B, Hamilton Dutoit SJ, Hansen HE, Olsen S. Acute tubulointerstitial nephritis: phenotype of infiltrating cells and prognostic impact of tubutitis. Virchows arch 1996;428:5-12.  Back to cited text no. 5    
6.Hawkins EP, Berry PL, Silva FG. Acute tubulointerstitial nephritis in children: clinical, morphologic, and lectin studies. Southwest Pediatric Nephrology Study Group. Am J. kidney Dis 1989;14:466-71.  Back to cited text no. 6    
7.Therese Vonternwyl, Pierre Sandoz Nephrites interstitielies aigues, Forum Med Suis 2003;38:178.  Back to cited text no. 7    

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Correspondence Address:
Fatima Mortajil
6, Rue Lacordaire, Residence WASDRAR, App. 19, France ville II, Casablanca
Morocco
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PMID: 16970260

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    Figures

  [Figure - 1], [Figure - 2]

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