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Abstract：
BACKGROUND: The renal involvement of brucellosis is not common. Here we reported a rare case of chronic brucellosis accompanied by nephritic syndrome, acute kidney injury, the coexistence of cryoglobulinemia and antineutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis (AAV) superimposed on iliac aortic stent implantation. The diagnosis and treatment of the case are instructive.
METHODS: A 49-year-old man with hypertension and iliac aortic stent implantation was admitted for unexplained renal failure with signs of nephritic syndrome, congestive heart failure, moderate anemia and livedoid change in the left sole with pain. His past history included chronic brucellosis and he just underwent the recurrence and completed the 6 weeks of antibiotics treatment. He demonstrated positive cytoplasmic/proteinase 3 ANCA, mixed type cryoglobulinemia and decreased C3. The kidney biopsy revealed endocapillary proliferative glomerulonephritis with a small amount of crescent formation. Immunofluorescence staining revealed only C3-positive staining. In accordance with clinical and laboratory findings, post-infective acute glomerulonephritis superimposed with AAV was diagnosed. The patient was treated with corticosteroids and antibiotics and sustained alleviation of renal function and brucellosis was achieved during the course of a 3-month follow-up.
CONCLUSIONS: Here we describe the diagnostic and treatment challenge in a patient with chronic brucellosis related glomerulonephritis accompanied by the coexistence of AAV and cryoglobulinemia. Renal biopsy confirmed the diagnosis of postinfectious acute glomerulonephritis overlapping with ANCA related crescentic glomerulonephritis, which was not ever reported in the literature. The patient showed a good response to steroid treatment which indicated the immunity-induced kidney injury. Meanwhile, it is essential to recognize and actively treat the coexisting brucellosis even when there are no clinical signs of the active stage of infection. This is the critical point for a salutary patient outcome for brucellosis associated renal complications.
METHODS: A 49-year-old man with hypertension and iliac aortic stent implantation was admitted for unexplained renal failure with signs of nephritic syndrome, congestive heart failure, moderate anemia and livedoid change in the left sole with pain. His past history included chronic brucellosis and he just underwent the recurrence and completed the 6 weeks of antibiotics treatment. He demonstrated positive cytoplasmic/proteinase 3 ANCA, mixed type cryoglobulinemia and decreased C3. The kidney biopsy revealed endocapillary proliferative glomerulonephritis with a small amount of crescent formation. Immunofluorescence staining revealed only C3-positive staining. In accordance with clinical and laboratory findings, post-infective acute glomerulonephritis superimposed with AAV was diagnosed. The patient was treated with corticosteroids and antibiotics and sustained alleviation of renal function and brucellosis was achieved during the course of a 3-month follow-up.
CONCLUSIONS: Here we describe the diagnostic and treatment challenge in a patient with chronic brucellosis related glomerulonephritis accompanied by the coexistence of AAV and cryoglobulinemia. Renal biopsy confirmed the diagnosis of postinfectious acute glomerulonephritis overlapping with ANCA related crescentic glomerulonephritis, which was not ever reported in the literature. The patient showed a good response to steroid treatment which indicated the immunity-induced kidney injury. Meanwhile, it is essential to recognize and actively treat the coexisting brucellosis even when there are no clinical signs of the active stage of infection. This is the critical point for a salutary patient outcome for brucellosis associated renal complications.
摘要：
背景：布鲁氏菌病的肾脏受累并不常见。在这里，我们报道了一例罕见的慢性布鲁氏菌病伴有肾病综合征，急性肾损伤，冷球蛋白血症和抗中性粒细胞胞浆自身抗体（ANCA）相关血管炎（AAV）的共存叠加在髂主动脉支架植入术上。该病例的诊断和治疗具有指导意义。
方法：一名49岁的高血压患者因不明原因的肾功能衰竭而入院，并伴有肾病综合征，充血性心力衰竭,左鞋底中度贫血和livedoid改变并伴有疼痛。他过去的病史包括慢性布鲁氏菌病，他刚刚经历了复发并完成了为期6周的抗生素治疗。他显示细胞质/蛋白酶3ANCA阳性，混合型冷球蛋白血症和C3降低。肾脏活检显示毛细血管内增生性肾小球肾炎，并有少量新月形成。免疫荧光染色显示仅C3阳性染色。根据临床和实验室检查结果，诊断为感染后急性肾小球肾炎合并AAV。患者接受皮质类固醇和抗生素治疗，并在3个月的随访过程中持续减轻肾功能和布鲁氏菌病。
结论：在这里，我们描述了伴有AAV和冷球蛋白血症共存的慢性布鲁氏菌病相关性肾小球肾炎患者的诊断和治疗挑战。肾活检证实感染后急性肾小球肾炎与ANCA相关的新月体肾炎重叠。这在文献中从未报道过。患者对类固醇治疗表现出良好的反应，表明免疫诱导的肾损伤。同时,即使没有感染活跃阶段的临床迹象，也必须识别并积极治疗共存的布鲁氏菌病。这是布鲁氏菌病相关肾脏并发症的患者预后的关键点。
方法：一名49岁的高血压患者因不明原因的肾功能衰竭而入院，并伴有肾病综合征，充血性心力衰竭,左鞋底中度贫血和livedoid改变并伴有疼痛。他过去的病史包括慢性布鲁氏菌病，他刚刚经历了复发并完成了为期6周的抗生素治疗。他显示细胞质/蛋白酶3ANCA阳性，混合型冷球蛋白血症和C3降低。肾脏活检显示毛细血管内增生性肾小球肾炎，并有少量新月形成。免疫荧光染色显示仅C3阳性染色。根据临床和实验室检查结果，诊断为感染后急性肾小球肾炎合并AAV。患者接受皮质类固醇和抗生素治疗，并在3个月的随访过程中持续减轻肾功能和布鲁氏菌病。
结论：在这里，我们描述了伴有AAV和冷球蛋白血症共存的慢性布鲁氏菌病相关性肾小球肾炎患者的诊断和治疗挑战。肾活检证实感染后急性肾小球肾炎与ANCA相关的新月体肾炎重叠。这在文献中从未报道过。患者对类固醇治疗表现出良好的反应，表明免疫诱导的肾损伤。同时,即使没有感染活跃阶段的临床迹象，也必须识别并积极治疗共存的布鲁氏菌病。这是布鲁氏菌病相关肾脏并发症的患者预后的关键点。
