A Case of Sarcoidosis in a Patient With IgA Nephropathy

Ayez Khan, MD; Neville Hodges, MD; Mark Lord, MD

Disclosures

March 29, 2005

Introduction

We present a patient with established immunoglobulin (Ig)A nephropathy who developed sarcoidosis.

A 41-year-old woman presented with 6 weeks history of persistent dry cough, exertional dyspnea, lethargy, a skin rash, and weight loss of 5 kg. She also noticed tender, swollen lumps associated with rash on her shins recently. She was a lifelong nonsmoker.

Three years ago, she had been diagnosed with IgA nephropathy on renal biopsy (see Figure 1). She had mild, stable renal impairment and there was no proteinuria or hypertension. She was not receiving any active medical treatment.

Renal biopsy sections showing mesangial expansion and hypercellularity in each of the glomeruli. Immunofluorescence microscopy showed marked granular positivity in the mesangium with a deposition of C3. These features of diffuse mesangial proliferative glomerulonephritis and positive Immunofluorescence are diagnostic of immunoglobulin (Ig)A nephropathy.

Physical examination showed that her body mass index was 29, respiratory rate 20/min, and blood pressure 130/70. There was no clubbing or lymphadenopathy. Cardiovascular examination was normal. There were fine crackles at the right lung base. Abdominal examination was normal. Eye and throat examinations were unremarkable. She had erythema nodosum on her shins. Urine dipstick showed mild hematuria and proteinuria.

Biochemical profile showed normal liver function tests and serum calcium. Urea was 8.5 mmol/L (range, 2.5-7.5) and creatinine was 158 mcmol/L (range, 50-110); these values were stable over the last 2 years. All the hematologic indices were normal. Erythrocyte sedimentation rate (ESR) was 36 (range, 10-20). Her electrocardiogram (ECG) was normal. Chest x-ray showed bilateral hilar lymphadenopathy with patchy consolidation in the right lower zone. Serum angiotensin-converting enzyme level was 132 U/L (range, 20-54).

Full lung function tests showed a slightly reduced residual volume of 1.18 (77% of the predicted), and the carbon monooxide gas-transfer factor was reduced at 14.4 (58% of the predicted). Bronchoscopy showed a nodular lesion in left lower lobe. The bronchial biopsy (Figure 2) showed changes entirely consistent with sarcoidosis.

Bronchial biopsy sections showing a well-formed epithelioid cell granuloma with surrounding lymphocytes. There is no caeseation, and no giant cells are present. The entire biopsy consisted of similar granulomata. Ziehl-Neelsen staining showed no acid alcohol fast bacilli. The presence of such granulomata is typical of sarcoidosis.

In view of her symptoms, radiologic abnormality, and reduced transfer factor, a trial of corticosteroids with 60 mg of prednisolone was undertaken.

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