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Diagnosis: Postinfectious glomerulonephritis with crescentic proliferation

Two interesting aspects in this case are the serologic test and the prominent humps seen in the biopsy.

Tests showing ANAs (title: 1/160, speckled pattern) and anti-DNA positivity (title: 1/20, repeated) are suspicious for systemic lupus erythematosus (SLE). SLE diagnosis requires a complete clinical and laboratory evaluation and to diagnose this disease several criteria are required. Only renal involvement is not sufficient to diagnose SLE. Positive ANAs are a frequent result in normal patients or those with other diseases (Muro Y. Antinuclear antibodies. Autoimmunity. 2005 Feb;38(1):3-9. [PubMed link]). Anti-DNA antibodies are more specific for SLE; however they are not per se “diagnostic” of lupus (Riboldi P, et al. Anti-DNA antibodies: a diagnostic and prognostic tool for systemic lupus erythematosus? Autoimmunity. 2005 Feb;38(1):39-45. [PubMed link]). SLE is never diagnosed by the renal biopsy; it can only complement criteria for the diagnosis.

In cases of endocapillary diffuse proliferative lupus nephritis (class IV lesions) usually there is "full house" deposition of immunoglobulins and complement fractions. In our case, the ausence of C1q deposition does not suggest lupus nephritis.

The humps are a characteristic lesion in postinfectious glomerulonephritis. They are almost pathognomonic of the disease, however a complete clinical history and paraclinical tests are important confirming this diagnosis. As always, a complete clinical-pathological correlation is essential. In the case that we present are prominent and extensive (fuschinofílic in Figure 6).

Crescentic proliferation is not exceptional in postinfectious GN, as seen in our case. Prognosis can be worsened when extensive crescentic proliferation is evidenced. As in all the renal biopsies, crescents must be reported and quantified.

See the chapter Proliferative Endocapillary Glomerulonephritis in our Tutorial.

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Bibliography

• Nasr SH, Markowitz GS, Stokes MB, Said SM, Valeri AM, D'Agati VD. Acute postinfectious glomerulonephritis in the modern era: experience with 86 adults and review of the literature. Medicine (Baltimore). 2008 Jan;87(1):21-32. [PubMed link]
• Ahn SY, Ingulli E. Acute poststreptococcal glomerulonephritis: an update.Curr Opin Pediatr. 2008 Apr;20(2):157-62. [PubMed link]
• Rodriguez-Iturbe B, Batsford S. Pathogenesis of poststreptococcal glomerulonephritis a century after Clemens von Pirquet. Kidney Int. 2007;71:1094-104. [PubMed link]
• El-Husseini AA, Sheashaa HA, Sabry AA, Moustafa FE, Sobh MA. Acute postinfectious crescentic glomerulonephritis: clinicopathologic presentation and risk factors. Int Urol Nephrol. 2005;37(3):603-9. [PubMed link]
• Muro Y. Antinuclear antibodies. Autoimmunity. 2005 Feb;38(1):3-9. [PubMed link]
• Riboldi P, Gerosa M, Moroni G, Radice A, Allegri F, Sinico A, Tincani A, Meroni PL. Anti-DNA antibodies: a diagnostic and prognostic tool for systemic lupus erythematosus? Autoimmunity. 2005 Feb;38(1):39-45. [PubMed link]
• Jennette C. et al. Heptinstall's Pathology of the Kidney, 6th edition, 2007.
• Ruiz P, Soares MF. Acute postinfectious glomerulonephritis: an immune response gone bad? Hum Pathol. 2003 Jan;34(1):1-2. [PubMed link]

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