A case report of unusually long lag time between immunotactoid glomerulopathy (itg) diagnosis and diffuse large B-cell lymphoma (DLBCL) development


Background:
Immunotactoid glomerulopathy (ITG) is a rare cause of proteinuria characterized by organized microtubular deposits in the glomerulus. ITG has been associated with underlying lymphoproliferative disorders and any renal impairment may be reversible with treatment of the concomitant hematologic malignancy. This case is the first reported in literature where diffuse large B cell lymphoma developed two years following the initial ITG diagnosis.

Case presentation:
A 55-year-old woman with a history of well-controlled diabetes mellitus and thalassemia trait presented with proteinuria (830 mg/day) in 2010. Initially, she was managed with renin-angiotensin-aldosterone-system blockade. In 2012, the proteinuria worsened (4.3 g/day) and a renal biopsy showed immunotactoid glomerulopathy (Fig. 1). Despite extensive work up, no lymphoproliferative disorder was initially found. In January 2014, the patient presented with a soft-palate mass found on biopsy to be diffuse large B-cell lymphoma. She received 6 cycles of R-CHOP, 4 cycles of high dose methotrexate chemotherapy for CNS prophylaxis and 30 Gy of Intensity Modulated Radiation Therapy. Follow-up revealed complete remission of diffuse large B-cell lymphoma and resolution of proteinuria from the ITG.

Conclusion:
As we recognize that patients with ITG may develop hematopoietic neoplasms, close long-term monitoring is important. Moreover, treatment of the lymphoproliferative disorder can allow for complete remission of ITG.

Keywords:
Immunotactoid glomerulopathy, Lymphoproliferative disorder, Monoclonal gammopathy of renal significance


Autoři: Aditi Khandelwal 1;  Martina A. Trinkaus 2;  Hassan Ghaffar 2;  Serge Jothy 2;  Marc B. Goldstein 2*
Působiště autorů: Department of Medicine, University of Toronto, Suite RFE 3-805, 00 Elizabeth Street, Toronto, ON M5G C4, Canada. 1;  Department of Laboratory Medicine, St. Michael’s Hospital and Department of Laboratory Medicine and Pathobiology, Univesity of Toronto, 30 Bond Street, Toronto, ON M5B 1W8, Canada. 2
Vyšlo v časopise: BMC Nefrol 2016, 17:140
Kategorie: Case report
prolekare.web.journal.doi_sk: 10.1186/s12882-016-0349-9

© 2016 The Author(s).

Open access
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
The electronic version of this article is the complete one and can be found online at: http://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-016-0349-9

Souhrn

Background:
Immunotactoid glomerulopathy (ITG) is a rare cause of proteinuria characterized by organized microtubular deposits in the glomerulus. ITG has been associated with underlying lymphoproliferative disorders and any renal impairment may be reversible with treatment of the concomitant hematologic malignancy. This case is the first reported in literature where diffuse large B cell lymphoma developed two years following the initial ITG diagnosis.

Case presentation:
A 55-year-old woman with a history of well-controlled diabetes mellitus and thalassemia trait presented with proteinuria (830 mg/day) in 2010. Initially, she was managed with renin-angiotensin-aldosterone-system blockade. In 2012, the proteinuria worsened (4.3 g/day) and a renal biopsy showed immunotactoid glomerulopathy (Fig. 1). Despite extensive work up, no lymphoproliferative disorder was initially found. In January 2014, the patient presented with a soft-palate mass found on biopsy to be diffuse large B-cell lymphoma. She received 6 cycles of R-CHOP, 4 cycles of high dose methotrexate chemotherapy for CNS prophylaxis and 30 Gy of Intensity Modulated Radiation Therapy. Follow-up revealed complete remission of diffuse large B-cell lymphoma and resolution of proteinuria from the ITG.

Conclusion:
As we recognize that patients with ITG may develop hematopoietic neoplasms, close long-term monitoring is important. Moreover, treatment of the lymphoproliferative disorder can allow for complete remission of ITG.

Keywords:
Immunotactoid glomerulopathy, Lymphoproliferative disorder, Monoclonal gammopathy of renal significance


Zdroje

1. Schwartz MM, Lewis EJ. The quarterly case: nephrotic syndrome in a middle-aged man. Ultrastruct Pathol. 1980;1(4):575–82.

2. Bridoux F, Hugue V, Coldefy O, et al. Fibrillary glomerulonephritis and immunotactoid (microtubular) glomerulopathy are associated with distinct immunologic features. Kidney Int. 2002;62:1764–75.

3. Schwartz M, Korbet SM, Lewis EJ. Immunotactoid glomerulopathy. J Am Soc Nephrol. 2002;13(5):1390–7.

4. Pronovost PH, Brady HR, Gunning ME, et al. Clinical features, predictors of disease progression and outcome of renal transplantation in fibrillary glomerulopathy and immunotactoid glomerulopathy. J Am Soc Nephrol. 1996;11(5):837–342.

5. Alpers CE, Kowalewska J. Fibrillary Glomerulonephritis and immunotactoid glomerulopathy. J Am Soc Nephrol. 2008;19:34–7.

6. Nasr SH, Cornell LD, Leung N, et al. Immunotactoid glomerulopathy: clinicopathologic and proteomic study. Nephrol Dial Transplant. 2012;27(11):4137–46.

7. Rosenstock JL, Markowitz GS, Valeri AM, et al. Fibrillary and immunotactoid glomerulonephritis: distinct entities with different clinical and pathological features. Kidney Int. 2003;63:1450–61.

8. Fermand JP, Bridoux F, Kyle RA, et al. International kidney and monoclonal gammopathy research group. How I treat monoclonal gammopathy of renal significance (MGRS). Blood. 2013;122(22):3583–90.

9. Leung N, Bridoux F, Hutchison CA, et al. International kidney and monoclonal gammopathy research group. Monoclonal gammopathy of renal significance: when MGUS is no longer undetermined or insignificant. Blood. 2012;120(22):4292–5.

10. Jacobson E, Sharp G, Rimmer J, et al. 59-year-old-woman with immunotactoid glomerulopathy, heavy-chain disease, and non-hodgkin lymphoma. Arch Pathol Lab Med. 2004;128(6):689–92.

11. Pronovost PH, Brady HR, Gunning ME, et al. Clinical features, predictors of disease progression and results of renal transplantation in fibrillary/immunotactoid glomerulopathy. Nephrol Dial Transplant. 1996;11(5):837–42.

12. Fogo A, Qureshi N, Horn RG. Morphologic and clinical features of fibrillary glomerulonephritis versus immunotactoid glomerulopathy. Am J Kidney Dis. 1993;22:367–77.

13. Jabur WL, Saeed HM, Abdulla K. Plasma cell dyscrasia; LCDD vs. immunotactoid glomerulopathy. Saudi J Kidney Dis Transpl. 2008;19(5):802–5.

14. Matsushita K, Inayama Y, Fujimaki K, et al. Lobular membranoproliferative glomerulonephritis with organized microtubular monoclonal immunoglobulin deposits associated with B cell small lymphocytic lymphoma. Nephrol Dial Transplant. 2005;20:1273–4.

15. Castro JE, Diaz-Perez JA, Barajas-Gamboa J, et al. Chronic lymphocytic leukemia associated with immunotactoid glomerulopathy: a case report of successful treatment with high-dose methylprednisolone in combination with rituximab followed by alemtuzumab. Leuk Lymphoma. 2012;53(9):1835–8.

16. Vigil A, Oliet A, Gallar P, et al. Rapidly progressive immunotactoid glomerulopathy and multiple myeloma. Nephron. 1998;79(2):238–40.

17. Witzens-Harig M, Waldherr R, Beimler J, et al. Long-term remission of paraprotein-induced immunotactoid glomerulopathy after high-dose therapy and autologous blood stem cell transplantation. Ann Hematol. 2007;86(12):927–30.

Štítky
Detská nefrológia Nefrológia
Prihlásenie
Zabudnuté heslo

Nemáte účet?  Registrujte sa

Zabudnuté heslo

Zadajte e-mailovú adresu, s ktorou ste vytvárali účet. Budú Vám na ňu zasielané informácie k nastaveniu nového hesla.

Prihlásenie

Nemáte účet?  Registrujte sa