结节病以多种方式出现,但历史上,肾脏受累被认为是罕见的,发病率为0.7%,很少是该疾病的表现特征。同时累及肾脏和骨髓极为罕见。非典型的表现形式,比如在这种情况下,可能会带来真正的诊断挑战。一名20岁的非裔美国男性出现在急诊科,症状模糊,包括疲劳,萎靡不振,厌食症,右侧下背部疼痛,和恶心。急性肾损伤明显,肌酐为19.78mg/dL(正常范围0.60-1.20mg/dL),BUN为124.0mg/dL(正常范围5.0-25.0mg/dL)。白细胞减少症的实验室结果也很显著,小细胞性贫血,高钾血症,阴离子间隙代谢性酸中毒,和非PTH依赖性高钙血症。有趣的是,尿液分析是模棱两可的,胸部X线(CXR)和腹盆腔计算机断层扫描(CT)扫描均未显示。患者入院,需要肾脏替代疗法以稳定其临床状况,同时计划随后进行肾脏活检。在等待病理结果时,全血细胞减少症发展,然后进行骨髓活检。在进一步调查中,血管紧张素转换酶(ACE)显着升高,提示结节病。肾活检显示中度急性肾小管损伤,血管炎,广泛的间质性水肿,和大量非干酪样肉芽肿的浸润,证实了结节病的诊断。骨髓组织病理学显示细胞减少,但无肉芽肿浸润。病人在整个住院期间基本上无症状,没有迹象或症状表明其他器官受累。开始使用大剂量皮质类固醇,出院后继续门诊治疗,同时仍在进行血液透析。在糖皮质激素和肾功能改善时,全血细胞减少症消退,在使用类固醇大约两个月后,肾脏替代治疗不再需要.总的来说,在之前健康的20岁患者中,严重到需要血液透析的肾损伤与全血细胞减少症相关,这是一种相当罕见的结节病表现.这突出了将结节病视为肾脏和骨髓功能障碍的可能原因的重要性,并强调需要及时进行活检以促进准确诊断并尽早开始适当的治疗,以避免延迟或不充分的护理。特别是考虑到即使是严重的损伤也可能是可逆的,如果及早发现并及时治疗。
Sarcoidosis presents in a variety of ways, but historically, renal involvement has been considered rare with an incidence of 0.7% and is seldom the presenting feature of the illness. Concomitant involvement of kidney and bone marrow is extremely rare. Atypical forms of presentation, such as in this case, may pose a true diagnostic challenge. A 20-year-old African-American male presented to the emergency department with vague symptoms including fatigue, malaise, anorexia, right-sided lower back pain, and nausea. Acute kidney injury was clearly evident, creatinine was 19.78 mg/dL (normal range 0.60-1.20 mg/dL), and BUN was 124.0 mg/dL (normal range 5.0-25.0 mg/dL). Laboratory results were also remarkable for leukopenia, microcytic anemia, hyperkalemia, anion gap metabolic acidosis, and non-PTH dependent hypercalcemia. Interestingly, urinalysis was equivocal and both chest x-ray (CXR) and abdominopelvic computed tomography (CT) scan were unrevealing. The patient was admitted to the hospital and required renal replacement therapy to stabilize his clinical condition while planning for a renal biopsy that was later performed. While awaiting pathological results,
pancytopenia developed, and a bone marrow biopsy was then obtained. On further investigation, angiotensin-converting enzyme (ACE) turned out to be significantly elevated suggesting sarcoidosis. Renal biopsy showed moderate acute tubular injury, tubulitis, extensive interstitial edema, and infiltration by numerous non-caseating granulomas, which confirmed the diagnosis of sarcoidosis. Bone marrow histopathology revealed hypocellularity but no granulomatous infiltration. The patient remained largely asymptomatic throughout his hospital stay, with no signs or symptoms suggesting the involvement of other organs. High-dose corticosteroids were started and continued outpatient after discharge while still on hemodialysis.
Pancytopenia resolved while on glucocorticoids and improvement in renal function was such that after roughly two months of steroids, renal replacement therapy was no longer necessary. Overall, kidney injury severe enough to require hemodialysis associated with
pancytopenia in a previously healthy 20-year-old constitutes a rather rare sarcoidosis presentation. This highlights the importance of considering sarcoidosis as a possible cause of kidney and bone marrow dysfunction and emphasizes the need for timely biopsy to facilitate accurate diagnosis and early initiation of appropriate therapy to avoid delayed or inadequate care, especially considering that even severe damage is potentially reversible when identified early and treated promptly.