1087

Recurrence of Henoch Schoenlein purpura nephritis associated

with tuberculous pleuritis

MASAKAZU WASHIO, FUMIO NANISHI, KAORU ONOYAMA,

KENICHIRO FUJII, NOBUAKI OHCHI and MASATOSHI FUJISHIMA

Second Department of Internal Medicine, Faculty of Medicine,

Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812, Japan

Key words: recurrence, Henoch Schoenlein purpura nephritis, tuberculous pleuritis

Abstract

The case of a 21-year-old male with recurrent Henoch Schoenlein purpura nephritis associated with
tuberculous pleuritis is reported. Following tuberculotherapy, polyclonal increases in the serum IgA and
IgG were normalized, and proteinuria and hematuria disappeared. These findings suggest that the tuberculous
pleuritis might have played a key role in the genesis of the recurrence of Henoch Schoenlein purpura nephritis
in this case.

Introduction months.
In one month prior to admission,
As factors implicated in the etiology of Henoch he noticed right chest pain on inspiration and a
Schoenlein purpura (HSP), infection, allergy and chest X-ray revealed a right pleural effusion. Two
immunological processes have been emphasized. weeks later, malaise, high fever, macroscopic
However, the true mechanism still remains to be hematuria and purpura in both legs appeared.
clarified. Upper respiratory tract infection precedes Repeated bacterial cultures of arterial blood and
30 to 80Qloof HSP patients [1] and streptococci the pleural effusion were all sterile and antibiotic
are considered as major infecting agents. However, therapy was ineffective. He had no family, history
the association of pulmonary tuberculosis is rare of tuberculosis.
in previous reports [2-5]. On admission, his body weight was 58.0 kg,
The present patient had HSP nephritis with height 171 cm, blood pressure 128/58 mmHg, and
tuberculous pleuritis and was cured by body temperature 38.7°C. The breath sounds were
tuberculotherapy. normal but decreased in the right middle and lower
Case Report lung fields, where dull percussion and faint vocal
fremitus were present. Old purpura was observed
A 21-year-old male was admitted to on both legs.
on because Laboratory studies yielded the following data:
of malaise, high fever, macroscopic hematuria and leukocyte count, 7,200/cumm; hematocrit, 4010,
proteinuria. platelets, 320,000/cumm; ESR, 51 mm/hr; serum
In he had developed purpura,
creatinine, 1.8 mg/dl; and creatinine clearance,
macroscopic hematuria and proteinuria 2 weeks
39.0 ml/min. The urinary protein was 3 + and the
after a common cold and was diagnosed as having
sediment contained numerous red blood cells. A
HSP nephritis. Following steroid therapy, the
24-hour specimen of urine contained 9.4 g of
proteinuria and hematuria disappeared within 6 protein. A chest X-ray revealed a marked pleural
Received February 16, 1988 effusion in the right chest (Fig. 1).

Japanese Journal of Nephrology Vol. 30, No. 9, 1988 25

 1088 Masakazu Washio, et al.

Fig. 1. Chest X-ray on admission, showing a marked pleural effusion in the right chest .

Repeated bacterial cultures of arterial blood, the

pleural effusion and urine were all negative. PPD
of intermediate strength resulted in 12 x 13 mm
of induration at 48 hours.
C-reactive protein was 7 +. ASLO, ASK,
antinuclear antibody, the LE test and latex fixa-
tion for rheumatoid factor were all negative.
Serological tests for hepatitis B virus and syphilis
were negative. The C3, C4 and CH50 levels were
within the normal range. The serum
immunoglobulin showed polyclonal increases in
IgG and IgA, at 2,481 mg/dl and 745 mg/dl,
respectively.
A pleural biopsy revealed epithelioid cells and
Langhans' giant cells, specific for tuberculous
pleuritis.
As shown in Fig. 2, the patient was treated with
isoniazid (INH), rifampicin (RF) and ethambutol
(EB). The fever resolved within a week. Improve-
ment of the pleuritis tuberculosa was accompanied
by disappearance of the macroscopic hematuria
and reduction of the proteinuria. With repeated Fig. 2. Clinical course of the present case.

26 Japanese Journal of Nephrologv Vol. 30, No. 9 , 1988

Recurrence of Henoch Schoenlein purpura nephritis
pleural lavage and intrapleural administration of
streptomycin (SM), C-reactive protein became
negative. In accordance with reduction in the
serum level of IgA, the serum creatinine was
restored to within the normal range, the creatinine
clearance was improved to 84.0 ml/min, and the
proteinuria decreased to 0.1 g/day. Microscopic
hematuria and proteinuria disappeared completely
within a year.
Percutaneous renal biopsy was performed on
By light microscopy, most of
the glomeruli revealed a focal segmental increase
in mesangial matrix. By immunofluorescent
microscopy, granular deposits of IgA and C3 were
prominent in the mesangial areas.
Discussion
In HSP nephritis, IgA deposition is
characteristically observed in the glomerular
mesangium as well as in the small vessel walls in
the skin [1, 6, 7]. Similar immunofluorescent
findings in the kidney and skin are seen in primary
IgA nephropathy (Berger's disease) [1, 6, 7].
Clinically, these diseases are characterized by
hematuria and proteinuria, occurring shortly after
the onset of respiratory tract infection. A similarity
in pathogenesis has been suggested between the two
diseases [1, 6].
In upper respiratory tract infections, the
mucous membrane is a major site of antigen
presentation and IgA is the predominant isotype
produced by the mucosal plasma cells. Upper
respiratory tract infection is therefore considered
to play an important role in the pathogenesis of
HSP nephritis and IgA nephropathy [1, 6, 7]. The
mucosae of the lower respiratory tract, such as of
the pulmonary bronchioles and alveolar spaces, are
also protected by IgA and IgM [8-10], suggesting
that lower respiratory tract infections may also be
correlated to the genesis of IgA mediated
glomerular diseases.
In addition to the protective role of cellular
immunity against mycobacterial infection, eleva-
tion of the serum levels of IgA and IgG is also
associated with pulmonary tuberculosis [11, 12].
Cohen and Elliot [13] reported polyclonal increases
in IgA and IgG in a case of IgA nephropathy
Japanese Journal of Nephrology Vol. 30, No. 9, 1988
associated with tuberculous pleuritis 1089
associated with disseminated tuberculosis.
In the present case, the elevated polyclonal
immunoglobulins, such as IgA and IgG, decreased
to normal levels in accordance with improvement
of the tuberculous pleuritis following
tuberculotherapy. The clinical signs such as
proteinuria and hematuria were also concomitantly
diminished. These findings suggest a close correla-
tion between tuberculous pleuritis and HSP
nephritis in the present case.
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