Rapidly progressive glomerulonephritis in a patient with syphilis

Rapidly Progressive Glomerulonephritis in a Patient with Syphilis Identification of Antitreponemal Antibody and Treponemal Antigen in Renal Tissue

PATRICK ERIN

GLAYOL JOHN

D. WALKER,

C. DEEVES, SAHBA

D. WALLIN,

WILLIAM

M.D.

B.S.

M.D.

M. O’NEILL,

Jr.,

M.D.

New Orleans, Louisiana

From the Departments of Pathology and internal Medicine (Nephrology), Tulane University School of Medicine, New Orleans, Louisiana. This work was presented in part at the 7 1st Annual Meeting of the United States-Canadian Division of the International Academy of Pathology, Boston, Massachusetts, March 1982. Requests for reprints should be addressed to Dr. Patrick D. Walker, Department of Pathology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112. Manuscript accepted June 23, 1983.

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A 37-year-old man presented with biopsy-proved rapidly progressive glomerulonephritis and a strongly positive fluorescent treponemal antibody result. The patient was treated with hemodialysis, plasmapheresls, methylprednisolone, and penicillin, with rapid lmprovement and stabilization of renal function. Antibody was eluted from the frozen renal tissue and demonstrated a strongly positive reaction to the treponemal antigen when used in the fluorescent treponemal antibody test. In addition, when specific rabbit antitreponemal antiserum was applied to the frozen renal sections, there was a strongly positive reaction. Although syphilis has been associated with membranous glomerulopathy and post-infectious giomerulonephritis, this appears to be the first case of latent syphilis in which rapidly progressive glomerulonephritls has been identified. The presence within the glomeruli of treponemal antigen and antitreponemal antibody supports the association of these two entities. Renal disease is a well-studied, although uncommon, complication of syphilis. Thomas and Schur [l] reported syphilitic nephropathy in only 0.3 percent of 4,000 patients with secondary syphilis. The most frequent syphilitic glomerular disease described is membranous glomerulonephritis [2-41, although mild proliferative glomerulonephritis [5-71 secondary to syphilis has also been reported. Several authors have identified the presence of eiutable anti-treponemal antibodies or a treponemal antigen in the glomeruli of patients with syphilitic nephropathy, thereby confirming the association between the glomerular disease and the spirochetal infection [3-81. Antibiotic therapy of these cases usually results in rapid and complete resolution of the urinary abnormalities, permanent renal function impairment being rare [Q]. Rapidly progressive glomerulonephritis associated with secondary or latent syphilis has not previously been reported. Rapidly progressive glomerulonephritis typically has an insidious onset and is associated with rapid progression to end-stage renal disease or death [ 10,111. Histologically, there are numerous epithelial cell crescents in the glomeruli, and treatment is usually thought to be ineffective [ 111. We describe a patient with rapidly progressive glomerulonephritis associated with latent syphilis and document that the glomerular disorder was an immunologic consequence of the syphilitic infection. Treatment of the rapidly progressive glomerulonephritis in this patient with intravenous corticosteroids, plasmapheresis, and penicillin resulted in rapid, prolonged improvement in renal function but with persistent nephrotic syndrome. This patient represents the first re-

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of rapidly progressive glomerulonephritis with syphilis and, further, represents one of the few patients with rapidly progressive glomerulonephritis in whom an inciting antigen has been identified.

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the nephrotic syndrome. Repeated VRDL testing still gave positive results at a 1:2 dilution, and urinalysis showed only severe proteinuria, oval fat bodies, and occasional renal tubular epithelial cells. METHODS

CASE REPORT A 37-year-old black man was transferred to Tulane Medical Center with a three-week history of dark urine, a decreased urine output, progressive swelling, and progressive lethargy. He had no known previous history of renal disease or hypertension. He denied any symptoms of pharyngitis, skin infection, skin rash, penile lesions, or penile discharge. He was unaware of any recent febrile illnesses. He denied joint pain or swelling and had no history of medication or drug use. Physical examination revealed a lethargic but oriented male with a blood pressure of 180/l 15 supine. His optic fundi showed moderate arteriolar narrowing. He had periorbital edema and 2+ pitting edema bilaterally in his lower extremities to the mid-tibia. Results of neurologic examination were normal except for the lethargy. Pertinent laboratory findings included the following: creatinine 21.6 mg/dl, blood urea nitrogen 186 mg/dl, sodium 134 meq/liter, potassium 6.2 meq/liter, chloride 93 meq/liter, bicarbonate 17 meq/liter, total protein 5.8 g/dl, albumin 2.6 g/dl, C3 156 mg/dl, C4 18 mg/dl, no antinuclear antibody, antistreptolysin 0 titer 1: 120, VDRL results positive at I:5 12 dilution; fluorescent treponemal antibody results positive at 1: 16 dilution. Urinalysis revealed 4-I protein and large heme; 100 red blood cells per high-power field, occasional oval fat bodies, and many red blood cell casts. Because of the urinary and clinical findings suggestive of a form of acute glomerulonephritis, open renal biopsy was performed on the second day of hospitalization. Short-term hemodialysis was instituted also. The presence of many epithelial cell crescents (greater than 90 percent) on light microscopic examination of the renal tissue led us to initiate therapy with intravenous methylprednisolone according to previously published guidelines [12] and also to begin plasmapheresis on a thrice-weekly schedule. Upon recognition of the positive VDRL and fluorescent treponemal antibody results (VDRL gave positive results in the spinal fluid as well), therapy with benzathine penicillin was instituted at a dosage of 2.4 million units per week for four weeks. Over the next two weeks, the patient had a gradual, but sustained, increase in urine output accompanied by a reduction in serum creatinine to 5.6 mg/di after dialysis had been discontinued. Over the next two months, the serum creatinine fell to 1.7 mg/dl, and prednisone dosage was reduced to 20 mg a day. At that time, urine continued to show nephrotic levels of proteinuria with microscopic hematuria and rare red cell casts. The 24-hour urinary protein excretion at that time was 9.4 g. Repeated renal biopsy was then performed by a percutaneous route. The patient continued to do well, and prednisone was gradually reduced over the next two months and then discontinued. Twenty-two months later, the serum creatinine level was still in the range of 1.5 to 1.8 mg/dl, and he still had

Histopathologic Study. A portion of the first renal biopsy specimen was fixed in formalin and processed into glycol methacrylate; 2 p sections were cut and stained with hematoxylin and eosin, periodic acid-Schiff-alcian blue, or Jones silver. A segment of the renal cortex was minced into 1 mm cubes, fixed in 3 percent glutaraldehyde for two hours, washed in 0.1 M phosphate buffer (pH 7.5) post-fixed in 1 percent osmium tetroxide for one hour, dehydrated, and embedded in maraglas. Silver sections were obtained with an LKB 2088 Ultratome V ultramicrotome, stained with lead citrate and uranyl acetate, and examined in a Phillips 300 electron microscope. lmmunohistochemical Studies. Part of the renal biopsy specimen was snap-frozen in liquid nitrogen; 5 y sections were cut in a cryostat at -20°C, fixed in acetone, and stained with fluorescein-conjugated goat anti-human IgG, IgM, IgA, C3, C4, fibrinogen, or albumin (Meloy Laboratories, Springfield, VA). The elution studies were carried out according to a modification of the technique of Feltkamp and Boode [ 131. Fifteen to 40 frozen sections of the renal specimen were cut at 5 p and placed on a glass slide or in a test tube. The material on glass slides and in the tubes was then exposed to either 0.02 M citric acid buffer (pH 3.2) or phosphate-buffered saline (pH 7.4) overnight in a moisture chamber at 4’C. The eluate was aspirated from the glass slides with a syringe. The slides were then stained with fluorescein-conjugated goat anti-human IgG to test the effects of elution. The eluate was collected from the test tubes as the supernatant following centrifugation in a tabletop centrifuge at low speed for five minutes. The acidic eluate was neutralized by adding one volume of 0.4 M phosphate buffer (pH 8.3) to two volumes of eluate, and both the phosphate-buffered saline and the citric acid buffer eluates were stored at -70°C until used. Both eluates, a control 4-i- anti-treponemal human serum, and a 2+ nonspecific control (saprophytic Treponema) human serum were diluted with either phosphate-buffered saline or an absorbant composed of material from nonspecific treponemal organisms and placed in wells on slides containing Treponema pallidum (FTA-ABS Fluoro Kit, Clinical Sciences, Whippany, New Jersey). Direct immunofluorescent studies for the presence of treponemal antigen in the renal biopsy specimen were carried out with an antiserum against Treponema pallidum. The antiserum was prepared in outbred New Zealand white male rabbits, and monospecificity was demonstrated by microhemagglutination assay for Treponema pallidum and the fluorescent treponemal antibody test (the antibody was kindly donated by Dr. James Folds, University of North Carolina). Frozen renal tissue was cut into 5 p sections in a cryostat at -20°C, air-dried, washed in phosphate-buffered saline (pH 7.4) covered with rabbit anti-treponemal antibody for 30 minutes at 23’C in a moisture chamber, washed in phosphate-buffered saline for 15 minutes, and exposed to fluorescein-conjugated goat anti-rabbit IgG for 30 minutes in the

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Figure 1. Photomicrograph of initial renal biopsy specimen showing three glomeruli each containing a cellular crescent (periodic acid-Schiff and alcian blue stain; original magnification X 125, enlarged by 25 percent).

Figure 2. Photomicrograph of initial renal biopsy specimen showing a circumferenkl, celluiar c&scent, mesangial and endothelial cell proliferation, and n&trophilic infiltration (periodic acidSchiff and alcian blue stain; original magnification X 500, reduced by 5 percent).

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moisture chamber. After another 1Bminute wash in phosphate-buffered saline, the slides were covered in an aqueous mounting medium (Aqua-mount, Lerner Laboratories, New Haven, Connecticut). Control studies included omission of the anti-treponemal antibody and parallel tests using renal tissue from a patient with systemic lupus erythematosus known to contain human IgG by immunofluorescent study. All slides were examined with a Nikon Labophot microscope with an Episcopic fluorescence attachment and photographed with a Microflex UFX photomicrographic attachment. The second renal biopsy specimen was processed as just described for routine light, immunofluorescent, and electron microscopy. RESULTS Light microscopy of the initial biopsy specimen showed 58 glomeruli, 54 of which contained cellular crescents (93 percent) (Figure 1). The remaining glomeruli showed

mesangial and endothelial cell proliferation and an infiltration of neutrophils (Figure 2). The tubulointerstitial and vascular areas were unremarkable. lmmunofluorescent studies demonstrated IgG and C3 diffusely deposited within the capillary loops and fibrinogen in the crescents (Figure 3a, 3b). The remaining stains gave negative results. Electron microscopy revealed diffuse endothelial and mesangial cell proliferation. There was also a proliferation of parietal epithelial cells with entrapped leukocytes, fibrin, and red blood cells. There were many subepithelial hump-like electrondense deposits as well as subendothelial fibrillar deposits with a periodicity consistent with fibrin (Figure 4).

enal biopsy spec deposits of IgG within the capillaries (f/uorescein-conjugated, anti-human IgG; original magnification X 350, reduced by 30 percent). Bottom, glomerulus showing deposits of fibrinogen in the crescent (fluorescein-conjugated, anti-human fibrinogen; original magnification X 350, reduced by 30 percent).

Figure 4. Electron photomicrograph of originai renal biopsy specimen showing endothelial cell proliferation and numerous subepithelial &posits (lead citrate and umnyl acetate stain; original magnification X 7,500, reduced by 5 percent).

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proteinuria, minimal hematuria, and either normal or only modest renal functional impairment [ 1,2,8]. With the application of more recent histologic and ultrastructural techniques to renal tissue, a pathologic diagnosis of membranous glomerulonephritis has been noted to be associated with most reports of syphilitic nephritis. Less frequently, mild proliferative glomerulonephritis has been identified during an active syphilis infection [5]. The presence of acutely deteriorating glomerulonephritis associated with extensive epithelial cell crescent formation has not been reported previously in association with syphilis. Glomerular crescents in syphilitic glomerulonephritis have been noted in only two patients, both with congenital syphilis. A two-month-old girl with congenital syphilis and “acute glomerulonephritis” was noted at autopsy to have “considerable crescent formation” in her glomeruli [ 151. More recently, Wiggelinkhuizen et al [6,7] have described several patients with congenital

The slides of the biopsy specimen eluted with citric acid buffer showed almost complete elimination of immunofluorescent staining for IgG (Figure 5), suggesting successful elution of the antibody. There was no diminution of staining of the sections eluted with phosphate-buffered saline. The citric acid buffer eluate showed a 4-t reaction with Treponema pallidum (Figure 6, top), whereas the phosphate-buffered saline eluate failed to react (Figure 6, bottom). The controls, both positive and negative, gave the expected results. The sections stained with anti-treponemal antibody showed 2-F granular deposits within the capillary loops (Figure 7). The control slides gave negative results. The follow-up renal biopsy specimen showed four glomeruli, one of which was globally sclerotic. Two glomeruli contained healed crescents (Figure 6). The mesangial areas showed residual mild proliferation. lmmunofluorescent examination of the second biopsy specimen revealed focal, segmental granular deposits of IgG and IgM within the glomerular capillaries. The intensity had decreased to l+. Antibody elution studies were not performed on the follow-up specimen because of insufficient tissue. COMMENTS The occasional occurrence of renal abnormalities with active syphilis infections has been well documented since at least the early 1900s [ 141. Since that time, several authors have described the clinical picture of syphilitic nephritis as a disorder characterized by severe

Figure 6. Photomicrographs of flborescent studies for treponemal antibody. Top, 4-t staining of T. pallidurn by citric acid buffer eluate (citric acid buffer eluate and flooresceinconjugated anti-human IgG; original magnification X 500, reduced by 30 percent). Bottom, negative staining of T. pallidurn by phosphate-buffered saline eluate (phosphatebuffered saline eluate and fluoresceinconjugated anti-human IgG; original magnification X 500, reduced by 30 percent).

Figure 5. t of initial renal biopsy sp&imen following elution with citric acid buffer showing almost complete loss of staining for IgG. The negativity is highlighted by comparing the glomerulus to the negative tubules in the background (fluorescein-conjugated anti-human IgG; original magnification X 250, reduced by 15 percent).

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syphilis and proliferative glomerulonephritis. One of these patients, a four-month-old girl, had “frequent crescents” identified on renal biopsy. Our patient appears to be the first with acquired syphilis and the clinical and pathologic characteristics of rapidly progressive glomerulonephritis. The association between the luetic infection and this patient’s glomerular disease was further elucidated by the immunopathologic methods described. Previous studies of syphilis-associated membranous and proliferative glomerulopathies have demonstrated elutable anti-treponemal antibodies [3], treponemal antigens [4,5], or both in renal biopsy material [8]. Our elution studies document the presence of an antibody in the renal tissue directed against Treponema pallidum. Furthermore, indirect immunofluorescent staining using an antiserum developed against treponemal antigen confirmed the presence of such an antigen in the glomeruli. The identification of treponemal antigen and anti-treponemal antibody in the glomeruli of this patient strengthens the probability that the existing clinical syphilitic infection was responsible for the glomerulonephritis in this patient. In addition to the first-described association of rapidly progressive glomerulonephritis with latent syphilis, our patient represents the first

F&e 7. photomicrograph of initbl renal biopsy specimen showing positive granular fluorescent staining for anti-treponemal antigen within the glomerular capillaries (anti-treponemal antiserum and fluorescein-conjugated anti-rabbit IgG; original magnification X 350, enlarged by 20 percent).

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documented example of rapidly progressive glomerulonephritis in which a glomerular antigen and antibody have been characterized. Although spontaneous resolution of the glomerulonephritis associated with syphilis may occur, appropriate antibiotic therapy usually results in a rapid remission, and permanent renal functional impairment is uncommon. Rapidly progressive glomerulonephritis, on the other hand, typically results in the rapid development of permanent renal failure, particularly when greater than 70 percent of glomeruli are involved with significant epithelial cell crescents [IO, Ill. Only recently have specific therapies been reported to consistently alter the rapid clinical deterioration in patients with rapidly progressive glomerulonephritis. Several authors have reported a marked improvement in renal function and urinary abnormalities in patients with rapidly progressive glomerulonephritis when intravenous bolus methylprednisolone is used [ 12,161. Others have noted a beneficial effect of plasmapheresis in this disorder [ 171. On the basis of the initial appearance of the renal tissue, we elected to utilize both intravenous methylprednisolone and plasmapheresis in an attempt to treat our patient’s glomerular disorder. Upon recognition of the presence of secondary syphilis, treatment with penicillin was also begun. Whether the corticosteroids, plasmapheresis, or antibiotics were primarily responsible for the dramatic improvement in our patient’s renal failure cannot be determined. Complete return to normal renal function did not occur in our patient, as evidenced by the persistent nephrotic syndrome and mildly elevated serum creatinine levels. This persistent renal abnormality is probably a result of the severity of the initial glomerular insult and residual glomerular scarring.

Figure 8. Photomicrograph of second renal biopsy specimen showing two glomeruli. One contains a large area of segmental sclerosis, whereas the other is essentially unremarkable (periodic acid-Schiff and alcian blue stain: original magnification X 250, reduced by 30 percent).

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The immunopathologic documentation of the association between latent syphilis and rapidly progressive glomerulonephritis in our patient is of considerable interest. The development of an acute glomerulonephritis with many epithelial cell crescents and advanced renal failure can occur in association with a syphilitic infection. Of more significance, this specific glomerular disease with acute renal failure can be successfully treated with a reasonable likelihood of substantial renal recovery. The most appropriate therapeutic intervention cannot be ascertained from our single case, but the fact

that this severe glomerulonephritis-with a very poor prognosis-responded at all is noteworthy. The possibility of latent or secondary syphilis associated with rapidly progressive glomerulonephritis should be evaluated in an adult patient with a clinical picture compatible with acute glomerulonephritis. ACKNOWLEDGMENT We would like to thank Dr. James Folds of the University of North Carolina who generously contributed the anti-treponemal antiserum.

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