Pneumonia and glomerulonephritis caused by Mycoplasma

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Departments of Medicine and Pathology, Academic Medical Centre, ... 1998 European Renal Association–European Dialysis and Transplant ... Haematuria.
Nephrol Dial Transplant (1998) 13: 3208–3211

Nephrology Dialysis Transplantation

Case Report

Pneumonia and glomerulonephritis caused by Mycoplasma pneumoniae Roos van Westrhenen, Jan J. Weening and Raymond T. Krediet Departments of Medicine and Pathology, Academic Medical Centre, University of Amsterdam, The Netherlands

Key words: Mycoplasma pneumoniae; glomerulonephritis; acute renal failure; pneumonia

Introduction The combination of a pneumonia caused by an infection with Mycoplasma pneumoniae and histologically confirmed glomerulonephritis has been described in three children [1–3]. We report a case of a M. pneumonia in an adult patient with acute renal failure due to glomerulonephritis.

Case A 49-year-old nurse had a relatively unremarkable medical history except for an episode of pneumonia as a child and the presence of vitiligo on both hands and lower parts of the legs since 1969. In the beginning of December 1997, she suffered from a cold. Four weeks later the patient developed fever (mean temperature: 39°C ), dyspnoe and cough without sputum. The general practitioner prescribed amoxycillin and added clavulanic acid to this medication, but the patient became even more dyspnoeic and sputum turned green. One week after the onset of fever the patient was submitted to a local hospital where a chest X-ray showed diffuse peribronchial abnormalities and the medication was altered to claritromycin. Two days later the fever had risen to 41°C and medication was changed into erythromycin and cefuroxime. A bronchoalveolair lavage, performed the next day, showed granulocytes and was negative for Legionella. Two days later the patient developed symmetric pain and swelling of joints, oedema of the abdominal wall and face and asymmetric erythema. She also developed oliguria (128). Also the bronchial lavage fluid was positive with a titre exceeding 1:2048. The serum was positive for cold agglutinins, but no circulating cryoglobulins could be detected. Serum complement factor C3 was 0.28 g/l ( low), and C4 was 0.02 g/l ( low). Treatment with claritromycin was reinstituted. After four haemodialysis sessions renal function improved. Six weeks after discontinuation of dialysis the GFR (measured as the clearance of [125I ]iothalamate) had increased to 77 ml/min.

© 1998 European Renal Association–European Dialysis and Transplant Association

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Fig. 1. A glomerulus with diffuse intracapillary influx of leukocytes accompanied by mesangial and endothelial cell swelling and proliferation. Methenamine silver, ×350.

Fig. 2. An afferent arteriole with intravascular accumulation of proteinaceous material, possibly immunoglobulins. Methenamine silver, ×300.

Discussion Renal involvement in patients with a pneumonia caused by M. pneumoniae is rare. In a survey from the United Kingdom of 3962 renal biopsies obtained between 1798 and 1983, 80 (2%) were performed on patients suffering from systemic infection [4]. In 66 of these sufficient clinical information was available. In five cases the systemic infection present consisted of pneumonia. The causative organisms were Legionella pneumonphila, Q fever and Psittacosis, each in one

patient. The renal lesions reported were interstitial nephritis (Legionella), nephrocalcinosis (Q fever) and membranoproliferative glomerulonephritis (Psittacosis). The patients in whom no cause was found had membrano-proliferative (n=1) and mesangioproliferative glomerulonephritis (n=1) in their renal biopsy. In the literature eight cases of respiratory tract infections caused by M. pneumoniae, that had also signs of renal involvement have been described [1–3, 5–8]. In four of these a renal biopsy had been per-

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Fig. 3. Immunofluorescence reveals the intraglomerular accumulation of complement component C3. A similar distribution was found for IgG. IgM was more diffuse (×200).

formed. The clinical and pathological findings of these patients are summarized in Table 1. One adult patient had a tubulo-interstitial nephritis [5], and three children a proliferative glomerulonephritis. The histological picture was variable: in two children a dense deposit disease was found, one with extensive extracapillary proliferation. Intracapillary proliferative glomerulonephritis was

present in the other child [2]. We found a similar picture of intracapillary glomerulonephritis in our adult patient. It is not known why some patients react with an acute intracapillary proliferative glomerulonephritis and others with a type II membranoproliferative picture. It can be speculated that the duration of exposure to the antigen may be important for the type of glomerular response to injury. In our

Fig. 4. Electronmicrograph showing a glomerular capillary loop with accumulation of protein-like material of moderate density and without specific periodicity. Note the hypercellularity due to influx of leukocytes (×15 000).

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Table 1. Clinical and pathological findings in patients with renal involvement during pneumonia caused by infection with M.pneumoniae Age of patient (years)

Clinical manifestations

Renal biopsy

Serum complement

Cold agglutinins

Recovery

Reference

7

Pneumonia Haematuria Proteinuria Renal failure

C3 3 C4 N

+



[1]

8

Pneumonia Nephrotic syndrome Renal failure Pneumonia Haematuria Proteinuria Pneumonia Hepatitis Renal failure Haematuria Proteinuria Pneumonia Proteinuria Renal failure

Membrano-proliferative glomerulonephritis type II with extracapillary proliferation Membrano-proliferative glomerulonephritis type II Intracapillary proliferative glomerulonephritis Tubulointerstitial nephritis

C3N C4 nr

+

C3 3 C4 N

+

+, but persistent [3] urinary abnormali ties + [2]

C3 N C4 N

+

+

Intracapillary proliferative glomerulonephritis

C3 3 + C4 3

+

Present study

11 26

49

[6 ]

3, decreased; N, normal; nr, not reported.

patient an acute pneumonia was present that responded to adequate antibiotic treatment. This was also the case in the other patient with intracapillary glomerulonephritis [2]. The infection may have been more chronic in the two patients with membranoproliferative glomerulonephritis [1,3]. Similar to post-streptococcal glomerulonephritis serum complement C3 was decreased. In all patients cold agglutinins could be detected in the serum, confirming the presence of a mycoplasma infection. In our patient, the renal biopsy revealed a marked intravascular coagulation of proteinaceous material, possibly cold agglutinins. Whether this is a specific finding during infection with M. pneumoniae is uncertain. It appears from the patients described that the prognosis with regard to recovery of renal function is probably good, although the number of patients reported is limited. It is concluded that a pneumonia caused by an infection with M. pneumoniae can be associated with acute renal failure caused by a proliferative glomerulonephritis. The histological picture may be variable, but the prognosis is likely to be good.

References 1. Dumas R, Bascoul S, Baldet P et al. Glomerulone´phrite membrano-proliferative et maladie mycoplasmique. Arch Fr Pediatr 1976; 33: 783–794 2. Vitullo BB, O’Regan S, de Chadarevian JP, Kaplan BS. Mycoplasma pneumonia associated with acute glomerulonephritis. Nephron 1978; 21: 284–288 3. Cochat P, Coloc S, Bosshard S, Zech P, Traeger J. Glomerulone´phrite membranoproliferative et infection a` Mycoplasma pneumoniae. Arch Fr Pediatr 1985; 42: 29–31 4. Boulton Jones JM, Davison AM. Persistent infection as a cause of renal disease in patients submitted to renal biopsy: a report from the glomerulonephritis registry of the United Kingdom MRC. Quart J Med 1986; (New Series 58) 226: 123–132 5. Pasternack A, Helin H, Va¨nttinen T, Ja¨rventie G, Veskari T. Acute tubulointerstitial nephritis in a patient with Mycoplasma pneumoniae infection. Scand J Infect Dis 1979; 11: 85–90 6. Ladreyt JP, Freycon F. Etude e´tiologique de 141 observations de glome´rulone´phrite aigue¨. Pe´diatrie 1970; 25: 679–682 7. Lebacq E, Macabeo V, David L, Hermier M. Syndrome pneumone´phritique par infection probable a` M. pneumoniae. Pe´diatrie, 1974; 29: 843–848 8. Dournon E, Roussi J, Dechy H. Infection a` M. pneumoniae avec anticoagulant circulant, cryoglobuline´mie et manifestations syste´miques. Ann Med Interne 1980; 131: 173–176 Received for publication: 29.7.98 Accepted: 31.7.98