Immune deposits in the spleen of a patient with acute poststreptococcal glomerulonephritis (APSGN)

CLINICAL

IMMUNOLOGI’

ANU

IMMUKOPATHOLOGI

6, 306-311

( 1976)

Immune Deposits in the Spleen of a Patient Acute Poststreptococcal Glomerulonephritis (APSGN)]

with

ELENA Ossr*, ANTHONY PREZYNA, MARION SEPULVEDA, CHARLES ELWOOD, AND GIUSEPPE ANDRES Departments of Microbiology. Pathology. und Medicine. Stute York at Buffalo, New York 14214 and the Renal Immunoputhology the Buffalo General Hospital, Buffalo, New York

Uni~~ersity of NeM, Laboratory of 14214

Received February 19. 1976 In a 17-year-old boy with biopsy-proven acute poststreptococcal glomerulonephritis (ASPGN) a splenectomy was performed because of traumatic rupture 49 days after the onset of gross hematuria and 24 days after percutaneous renal biopsy. Granular deposits of Cs. properdin, and IgG were found in the walls of splenic venous sinuses and arterioles and in renal glomeruli. These findings support the hypothesis that APSGN is a systemic vascular disease characterized by generalized capillary damage secondary to the deposition of immune complexes.

INTRODUCTION

The immunopathologic features of APSGN are comparable to those of acute serum sickness glomerulonephritis induced in rabbits by an intravenous injection of foreign proteins. In this experimental model, circulating antigen-antibody complexes localize and produce injury not only in renal glomeruli but also in vascular structures of other organs (1). This paper describes the immunopathologic changes found in splenic and renal tissues from a patient with documented APSGN. Granular deposits of IgG, Car and properdin, similar to those found in renal glomeruli, were present in the walls of splenic arterioles and venous sinuses. These findings support the observations made early in this century by European clinicians (2-4) who proposed that streptococcal infections induce a systemic disease comparable to acute serum sickness. PATIENT AND METHODS

Patient In a 17-year-old white boy gross hematuria developed 1 week after an illness characterized by fever, chills, and myalgias. Hypertension and edema were noted 1 week later. Physical examination at the time of admission to the hospital in the fourth week of the illness revealed generalized pallor and edema of the eyelids. The blood pressure was 120180 and the heart rate 90imin and regular. The spleen was not palpable. 1 Aided by grants from the IJ. S. Public Health Service (AJ-10334) and the New York Kidney Disease Institute, Albany, New York (Contract 91271). * Fellow of the Italian Society of Nephrology. Copyright @ 1976 by Academic Press. Inc. All rights of reproduction in any form reserved.

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Laboratory studies. Hematocrit 34.7, ESR 10, serum creatinine 0.9, GFRRPF: 102/605 ml/min/1.73 m*, serum albumin 2.28 g&l, Cs, 51 (126265), C, 30 (20-50). ASO, 333 to higher than 572. Latex fixation, negative. Addis count: 240 million erythrocytes, 60 million leucocytes/24 hr. Urinary osmolality after Pitressin, 765 mosm/Kg. 24 hr urinary protein, 0.44 g. Percutaneous renal biopsy was performed. On the 48th day after the onset of hematuria, the patient was thrown from a toboggan and struck his left side. Pain in this area persisted and on the next day a ruptured spleen was removed. The postoperative course was uneventful. Methods

Renal tissue was obtained by percutaneous needle biopsy and splenic tissue by splenectomy 24 and 49 days, respectively, after the onset of hematuria. The tissues were processed for light, electron, and immunofluorescence microscopy (5). Paraffin sections were stained with hematoxylin and eosin, PAS, Masson, and silver-methenamine. Serial plastic sections, 1 pm thick obtained from seven glomeruli and from the spleen were stained with Toluidine blue and examined by light microscopy (6). Thinner, contiguous sections were studied by electronmicroscopy. Fluorescein-conjugated antibody of human IgG, IgM, IgA, fibrinogen, C, (Hayland Laboratories, Costa Mesa, California) C,q (5) Cd, and &PA (Cappel Laboratories, Inc., Downington, Pennsylvania) globulins were used in direct immunofluorescence tests. The rabbit antiserum to human properdin (a generous gift of Dr. Irwin H. Lepow (7)) was used in an indirect immunofluorescence test. Antisera to cell membrane or cell wall components of streptococci Group A, Type 12, 14, and 49 were kindly provided by Dr. John Zabriskie (8). The specificities of conjugates were tested by immunoelectrophoresis. Attempts to detect streptococcal antigens in kidney and spleen were performed in tissue sections which had been eluted with acid buffer (9) at 56°C for 30 min. The intensity and the extent of fluorescent staining were arbitrarily graded as: 0, negative; 2, minimal; + , slight; 2+, moderate; 3+, marked. RESULTS

By light microscopy, 50% of glomeruli present in paraffin sections appeared normal. The others were enlarged and showed increased amounts of mesangial matrix, mesangial cell proliferation, and accumulation of polymorphonuclear leukocytes. In paraffin sections stained with Masson, red deposits were seen on the epithelial side of glomerular basement membranes. In plastic sections stained with Toluidine blue, numerous subepithelial deposits (“humps”) were seen (Fig. 1) in all glomeruli examined. An average of 50 focal subepithelial deposits was counted in the glomerular structures contained in equatorial sections about 1 pm thick. The longitudinal diameter of the largest deposits was estimated at 2-5 pm since they were identifiable in 2-5 contiguous sections. If one assumes the presence of 50 “humps” for each glomerular section of 5 pm, one can calculate that about 1300 deposits were present within each glomerulus (glomerular diameter. 200 pm; circle area; r2 x r; volume, (? x 4?r). 3 Since the number of glomeruli has been estimated at about 1 million for each kidney (lo), this would represent a total of about 2,600,000,000 subepithelial deposits in both kidneys. The presence and large size of the subepithelial deposits was confirmed by examination of thin

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FIG. 1. Section of a renal glomerulus. Four deposits (arrows) are seen on the epithelial side of the basement membrane. Toluidine blue, x 1000.

sections with the electronmicroscope. Glomerular deposits of IgG (+I. C, (3+) (Fig. 2) and properdin (3+) were seen by immunofluorescence in glomerular cap& lary walls. Granular deposits corresponded in location to the dense deposits seen by light and electronmicroscopy. Other classes of immunoglobulins, other complement fractions, fibrinogen, and streptococcal antigens were not detected. Minimal congestion of the red pulp and increased number of polymorphonuclear leukocytes were found in the spleen. Foreign deposits were not identifiable in paraffin sections stained with Masson or in plastic sections stained with Toluidine blue. Examination by electron microscopy, however, showed electron-dense deposits along the basement membrane of venous sinuses (Fig. 3) and in the walls of splenic arterioles. Comparable granular deposits of C, (3+) (Fig. 4). properdin (3+) (Fig. 5) and, in slight amounts, IgG (+) (Fig. 6) were seen by immunofluorescence in the same areas.

FIG. 2. Granular deposits of C, in a renal glomerulus.

x250.

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FIG. 3. Electronmicrograph showing dense deposits (arrows) along the basement membrane (ar‘row heads) of a splenic venous sinus. 1, lumen of the venous sinus; N, nucleus of a macrophage in the red pulp. >(4000.

Frc. 4. Granular deposits of C3 along the walls of splenic venous sinuses (s). x600.

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5. Longitudinal

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section of a splenic arteriole. Granular deposits of properdin.

x

2 50.

DISCUSSION

Accurate clinical observations made by European clinicians early this c:entury drew a prophetic analogy between the immunological and clinical events c,f postscarlet fever glomerulonephritis and those of acute serum sickness. Schick (2). on the basis of circumstantial evidence, was the first to propose that APSG .N was induced by an antigen-antibody reaction. Von Pirquet (3), Volhard (4) and Klinge (11) suggested that some symptoms of APSGN, such as fluid retention and hyper-

FIG. 6. Granular deposits of IgG along the walls of splenic venous sinuses (S). R. red pulp. x600.

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tension, resulted from a “capillaritis universalis due to a condition of hypersensitivity.” During the last 15 years, this hypothesis has been strengthened by the demonstration of similarities between APSGN and the glomerulonephritis of rabbits with acute serum sickness. In both conditions, cellular proliferation, infiltration of polymorphonuclear leukocytes, and granular immune deposits are found in glomerular structures. Experimental acute serum sickness is a systemic disease induced by the deposition of circulating complement-binding antigen-antibody complexes in the kidneys, heart, joints, and vessels of several organs, including the spleen (1). The hypothesis that APSGN is also a systemic disease characterized by generalized hypersensitivity has been difftcult to substantiate because the illness is usually benign and tissues taken at autopsy early in the course of disease are only rarely available. Nor have biopsies of nonrenal tissues been performed. The present study shows that unusually large and numerous granular deposits of IgG, CQ, and properdin (12), were present in renal glomeruli. Comparable deposits were present in the venous sinuses and in the arterioles of the spleen 48 days after the clinical onset of APSGN. Only minimal congestion of the red pulp and a slight increase in number of polymorphonuclear leukocytes were associated with the immune deposits. Renal or spleen acute arteritis (13,14) were not observed. It has been well documented, however, that in APSGN the glomerular proliferative and exudative changes, which are associated with severe clinical symptoms may rapidly subside, whereas immune deposits persist in renal capillary walls for longer periods of time (15). Therefore, it is possible that in this patient acute inflammatory lesions may have been present in the spleen at an earlier stage of disease. REFERENCES 1. 2. 3. 4.

Dixon, F. J., In “Harvey Lectures,” Series 58, Academic Press, New York, 1963. Schick, B.,J&. Kinderheilk, 65, 132, 1907. Von Pirquet, C. E. Arch. Internal. Med. 7, 259, 1911. Volhard. F. In “Handbook der Inneren Medizin.” (L. Mohr, and R. Staehelin, Ed.), Springer. Berlin, 1918. 5. Andres, G. A., Accinni, L., Beiser, S. M., Christian, C. L., Cinotti, G. A., Erlanger, B. F., Hsu, K. C., and Seegal, B. C., J. Clin. Invest. 49, 2106, 1970. 6. Zamboni, L. Human Pathology, 3, 127, 1972. 7. Pensky, J., Hinz, C. F., Todd, E. W., Wedgwood, R. J., Boyer. J. T.. and Lepow, I. W.. J. Immunol. 100, 142, 1968. 8. Seegal, B. C., Andres, G. A., Hsu, K. C., and Zabriskie, J. B., Fed. Proceed. 24, 100, 1965. 9. KoMer, D., Schur, P.. and Kunkel, H. G.. J. Exp. Med. 126, 607, 1967. IO. Smith, H. W. “The Kidney. Structure and Function in Health and Disease,” Oxford University Press, New York, 1951. I I. Khnge, F. Beitr. Pathol. Anar. Allgem. Pathol. 83, 185, 1929. 12. Michael, A. F., Westberg, G. N., Fish, A. J., and Vernier, R. L., J. Exp. Med. 134, 208s 1971. 13. Fordham, C. C., Epstein, F. H.. Huffines. W. D., and Harrington, J. H.. Ann. In?. Med. 61, 89. 1964. 14. Andres, G. A., Accinni. L., Hsu. K. C., Zabriskie. J. B.. and Seegal, B. C.. J. Exp. Med. 123,399. 1966. 15. Corchrane, C. G., and Koffler, D. In “Advances in Immunology.” (Edited by F. J. Dixon, and H. G. Kunkel, Ed.), 16, 185. Academic Press, New York. 1973.