IgA为主型感染相关性肾小球肾炎伴草酸盐沉积1例及文献复习

doi:10.3969/j.issn.1004-583X.2025.02.012

临床荟萃 ›› 2025, Vol. 40 ›› Issue (2): 162-167.doi: 10.3969/j.issn.1004-583X.2025.02.012

IgA为主型感染相关性肾小球肾炎伴草酸盐沉积1例及文献复习

赵慧¹, 张鹏伟², 张健^3a, 黄文辉^3a, 李小丽^3a, 马志刚⁴, 金芳^3b, 田利民⁵()

1.甘肃中医药大学中西医结合学院,甘肃兰州 730000
2.甘肃定西市第二人民医院心内科,甘肃定西 743000
3.甘肃省人民医院 a.肾内科;b.党委办公室,甘肃兰州 730000
4.香港中文大学医学院(深圳)第二附属医院深圳市龙岗区人民医院肾内科, 广东深圳 518000
5.中国电子科技大学四川省人民医院内分泌科,四川成都 610000

收稿日期:2024-06-16 出版日期:2025-02-20 发布日期:2025-03-05
通讯作者: 田利民 E-mail:tlm7066@sina.com
基金资助:
甘肃省人民医院院内科研基金——膜性肾病患者B细胞激活因子(BAFF);预后评估的相关临床研究(22JR11RA265);甘肃省自然科学基金——KM55单克隆抗体在原发性IgA肾病患者中的临床意义(21JR7RA625);预后评估及复发的相关性研究(22GSSYB-12)

IgA-dominant infection-related glomerulonephritis with oxalate deposition: A case report and literature review

Zhao Hui¹, Zhang Pengwei², Zhang Jian^3a, Huang Wenhui^3a, Li Xiaoli^3a, Ma Zhigang⁴, Jin Fang^3b, Tian Limin⁵()

1. College of Integrated Traditional Chinese and Western Medicine, Gansu University of Chinese Medicine, Lanzhou 730000, China
2. Department of Cardiology, the Second People's Hospital of Dingxi City, Gansu Province, Dingxi 743000, China
3a. Department of Nephrology; b. Party Committee Office, Gansu Provincial Hospital, Lanzhou 730000, China
4. Department of Nephrology, Longgang District People's Hospital of Shenzhen, the Second Affiliated Hospital, School of Medicine, the Chinese University of Hong Kong-Shenzhen, Shenzhen 518000, China
5. Department of Endocrinology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610000, China

Received:2024-06-16 Online:2025-02-20 Published:2025-03-05
Contact: Tian Limin E-mail:tlm7066@sina.com

摘要/Abstract

摘要：

目的本文报道1例民间土法治疗关节炎致皮肤烫伤溃烂结痂愈合,后继发IgA为主型感染相关性肾小球肾炎(IgA-IRGN)伴草酸盐沉积患者,观察其临床病理特点,探讨心、肾、关节病变之间的相关关系。方法患者入院后完善心脏超声、膝关节MRI,行肾穿刺活检及关节腔内穿刺液培养,观察其临床病理特点及治疗后转归。结果经过抗感染、降尿蛋白、改善心功能等治疗后病情好转。结论 IgA-IRGN多见于2型糖尿病和免疫力低下的老年人群,该病例无上述基础疾病,肾病综合征表现合并急性肾损伤、骨性关节炎、重度二尖瓣关闭不全及二尖瓣脱垂,多病共存使得病情更为复杂。对于IgA-IRGN感染源隐匿时临床易误诊、漏诊,在诊治时需提高警惕。

关键词: 肾小球肾炎, IGA, 金黄色葡萄球菌, 骨关节炎

Abstract:

Objective This article reports a patient who developed immunoglobulin A (IgA)-dominant infection-related glomerulonephritis (IgA-IRGN) with oxalate deposition following skin burns, ulceration, scab formation, and healing caused by folk remedies for arthritis. To observe the clinicopathological features and explore the correlation between the heart, kidney and joint lesions. Methods After admission, the patient underwent echocardiography, knee joint magnetic resonance imaging (MRI), renal biopsy, and culture of synovial fluid from the joint cavity. The clinical and pathological characteristics were observed, and the outcomes after treatment were analyzed. Results The patient's condition improved after treatment with anti-infective therapy, proteinuria reduction, and cardiac function improvement. Conclusion IgA-IRGN is commonly seen in elderly individuals with type 2 diabetes and immunodeficiency. However, this case did not involve these underlying conditions. The patient presented with nephrotic syndrome, acute kidney injury, osteoarthritis, severe mitral regurgitation, and mitral valve prolapse. The condition is further complicated by the coexistence of multiple diseases. When the infection source of IgA-IRGN is occult, clinical misdiagnosis and missed diagnosis are common. Therefore, increased vigilance is needed during diagnosis and treatment.

Key words: glomerulonephritis, IGA, Staphylococcus aureus, osteoarthritis

中图分类号:

R692.31

赵慧, 张鹏伟, 张健, 黄文辉, 李小丽, 马志刚, 金芳, 田利民. IgA为主型感染相关性肾小球肾炎伴草酸盐沉积1例及文献复习[J]. 临床荟萃, 2025, 40(2): 162-167.

Zhao Hui, Zhang Pengwei, Zhang Jian, Huang Wenhui, Li Xiaoli, Ma Zhigang, Jin Fang, Tian Limin. IgA-dominant infection-related glomerulonephritis with oxalate deposition: A case report and literature review[J]. Clinical Focus, 2025, 40(2): 162-167.

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链接本文: https://lchc.magtechjournal.com/CN/10.3969/j.issn.1004-583X.2025.02.012

https://lchc.magtechjournal.com/CN/Y2025/V40/I2/162

图/表 5

图1 红斑样皮肤改变 a.肩胛骨部位皮肤溃烂结痂愈合,痂皮脱落; b.右下肢腘窝下皮肤结痂

Fig.1 Erythematous skin changes a. Skin ulceration and scab healing at scapula with detached scabs; b. Skin scab under popliteal fossa of the right lower limb

图2 膝关节影像 a、b.左膝关节正侧位平片:关节间隙变窄,见多发骨赘; c、d.左膝关节MRI:关节软骨厚薄不均,内侧半月板膨出,交叉韧带损伤

Fig.2 Knee joint images a, b. Anterior and lateral plain films of the left knee joint show narrowed joint space and multiple osteophytes; c, d. MRI of left knee joint shows uneven thickness of articular cartilage, swelling of medial meniscus and injury of cruciate ligament

图3 患者肾脏病理 a.肾小球毛细血管襻狭窄,内皮细胞和系膜细胞增生,蓝色箭头示小细胞性新月体,绿色箭头示中性粒细胞浸润(HE×200);b.肾小管腔内可见红细胞管型(HE×100);c.肾小管腔内可见圆盘状结晶,偏振光下可见双折光现象(偏振光×100);d1、d2. IgA、 C3沿毛细血管壁及系膜区呈粗大颗粒状沉积,C3强度高于IgA(免疫荧光×200); e.肾小球上皮下驼峰状电子致密物沉积(电镜×5000)

Fig.3 Patient renal pathology a. Glomerular capillary loops are narrow, with proliferating endothelial and mesangial cells, blue arrow shows small cell crescent body, green arrow shows neutrophil infiltration (HE×200); b. Red cell tube type can be seen in renal tubule lumen (HE×100); c. Disc crystals can be seen in the renal tubule lumen, and double refraction phenomenon can be seen under polarized light (polarized light ×100); d1, d2. IgA, C3 show coarse granular deposition along the capillary wall and mesangial region, and the intensity of C3 is higher than IgA (immunofluorescence ×200); e. Arrow shows the hump-like electron dense deposits under glomerular epithelium (electron microscope ×5000)

图4 免疫荧光染色 a.IgA免疫荧光染色(×400);b. KM55免疫荧光染色(×400);c.ab图像融合(免疫荧光×400);d. IgA肾病患者KM55阳性对照(免疫荧光×400)

Fig.4 Immunofluorescence staining a. IgA immunofluorescence staining (×400) ; b. KM55 for immunofluorescence staining (×400); c. ab image fusion (immunofluorescence ×400) ; d. KM55 for positive control (immunofluorescence ×400) in IgA nephropathy patients

表1 患者治疗前后化验指标变化情况

Tab.1 Changes in laboratory indicators before and after treatment

指标	时间
指标	入院前半月	入院时	入院后第2 d	入院后第3 d	入院后第4 d	入院后第7 d	入院后第9 d	入院后2周	入院后2个月
白细胞(×10⁹/L)	7.51	8.9	-	5.7	-	10.6	13.1	10.5	8.5
血红蛋白(g/L)	131	115	-	116	-	107	109	100	115
血小板(×10⁹/L)	309	390	-	436	-	431	396	136	367
白蛋白(g/L)	30	24.37	-	26.9	-	30.2	32.7	31.6	36
尿素氮(mmol/L)	42.1	42.6	54.9	42	44.89	44.9	34.3	16.9	12
血肌酐(μmol/L)	752	453.8	431	346	337	200	141.3	109.7	85
Ca(mmol/L)	2.11	1.93	1.82	1.9	2.1	2.2	2.14	1.94	1.98
P(mmol/L)	1.55	1.9	-	-	-	-	-	-	-
K(mmol/L)	5.39	5.4	5.1	5.3	5.1	4.8	4.5	3.5	4.2
CRP(mg/L)	49.8	127.6	-	105	-	27.7	15.2	-	12
PCT(ng/ml)	-	1.316	-	-	-	0.078	-	0.090	-
血沉(mm/h)	89	-	61	-	-	-	-	8	6
C3(g/L)	-	-	0.2	-	-	-	-	0.4	0.6
24h-UP(g/24h)	-	-	-	4.93	-	-	-	2.75	0.8

参考文献 30

[1]	Kambham N. Postinfectious glomerulonephritis[J]. Adv Anat Pathol, 2012, 19(5):338-347. doi: 10.1097/PAP.0b013e31826663d9 pmid: 22885383
[2]	Wagrowska-Danilewicz M, Danilewicz M, Fisiak I, et al. An unusual case of IgA-dominant postinfectious glomerulonephritis: A case report and review of the literature[J]. Pol J Pathol, 2016, 67(2):179-182. pmid: 27543874
[3]	Bu R, Li Q, Duan Z, et al. Clinicopathologic features of IgA-dominant infection associated glomerulonephfitis:A pooled analysis of 78 cases[J]. Am J Nephrol, 2015, 41(2):98-106.
[4]	Saad M, Daoud M, Nasr P, et al. IgA dominant post infectious glomemlonephritis presenting as a fatal pulmonary-renal syndrome[J]. Int J Nephrol Renovase Dis, 2015, 8(5):77-81.
[5]	Wen YK, Chen ML. IgA-dominant postinfeetious glomerulonephritis: Not peculiar to staphylococcal infection and diabetic patients[J]. Ren Fail, 2011, 33(5):480-485.
[6]	Satoskar AA, Molenda M, Scipio P, et al. Henoch-Schönlein purpura-like presentation in IgA-dominant Staphylococcus infection-associated glomerulonephritis-a diagnostic pitfall[J]. Clin Nephrol, 2013, 79(4):302-312. doi: 10.5414/CN107756 pmid: 23320971
[7]	Nasr SH, D'Agati VD. IgA dominant postinfectious glomerulonephritis:A new twist on old disease[J]. Nephron Clin Pract, 2011, 119(1):c18-c25.
[8]	Koyama A, Kobauashi M, Yamaguchi N, et al. Glomerulonephritis associated with MRSA infection: A possible role of bacterial superantigen[J]. Kidney Int, 1995, 47(1): 207-216. doi: 10.1038/ki.1995.25 pmid: 7731148
[9]	Yoh K, Kobayashi M, Hirayama A, et al. A case of superantigen-related glomerulonephritis after methicillin-resistant Staphylococcus aureus (MRSA) infection[J]. Clin Nephrol, 1997, 48(5):311-316. pmid: 9403216
[10]	Gaut JP, Mueller S, Liapis H. IgA dominant postinfectious glomerulonephfitis update:Pathology spectrum and disease mechanisms[J]. Diagn Histopathol, 2017, 23(3):126-132.
[11]	孙丽君, 王国勤, 叶楠, 等. IgA为主型感染相关性肾小球肾炎10例临床及病理特征分析[J]. 中国实用内科杂志, 2021, 41(8):700-704.
[12]	Wang SY, Bu R, Zhang Q, et al.Clinical, pathological, and prognostic characteristics of glomerulonephritis related to staphylococcal infection[J]. Medicine (Baltimore), 2016, 95(15):e3386.
[13]	Okuyama S, Wakui H, Maki N, et al. Successful treatment of post-MRSA infection glomerulonephritis with steroid therapy[J]. Clin Nephrol, 2008, 70(4):344-347. doi: 10.5414/cnp70344 pmid: 18826861
[14]	Evan AP, Lingeman JE, Coe FL, et al. Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle[J]. J Clin Invest, 2003, 111(5):607-616. doi: 10.1172/JCI17038 pmid: 12618515
[15]	Evan AP, Coe FL, Lingeman J, et al. Randall's plaque in stone formers originates in ascending thin limbs[J]. Am J Physiol Renal Physiol, 2018, 315(5):F1236-F1242.
[16]	Dickson FJ, Sayer JA. Nephrocalcinosis:A review of monogenic causes and insights they provide into this eterogeneous condition[J]. Int J Mol Sci, 2020, 21(1):369.
[17]	Hoppe B, Beck BB, Milliner DS. The primary hyperoxalurias[J]. Kidney Int, 2009, 75(12):1264-1271. doi: S0085-2538(15)53641-7 pmid: 19225556
[18]	杨微微, 苏涛. 继发性草酸盐肾病的研究进展[J]. 中华医学杂志, 2020, 101(28):2263-2266.
[19]	Karaolanis G, Lionaki S, Moris D, et al. Secondary hyperoxaluria:A risk factorfor kidney stone form ation and renal failure in native kidneys and renal grafts[J]. Transplantation Rev, 2014, 28(4):182-187.
[20]	Hoppe B yonUnruh G, Laube N, et al. Oxalatedegrading bacteria:New treatment option for patients with primary and secondary hyperoxaluria?[J]. Urol Res, 2005, 33(5):372-375.
[21]	Sikora P, Beck B, Zajaczkowska M, et al. Plasma oxalate level in pediatric calcium stoneformers with or without secondary hyperoxaluria[J]. Uroll Res, 2009, 37(2):101-105.
[22]	李怀智. 大剂量维生素C引起急性草酸盐肾病[J]. 国外医学(内科学分册), 1986, 1(7):334-335.
[23]	Remenyi B, ElGuindy A, Smith SC Jr, et al. Valvular aspects of rheumatic heart disease[J]. Lancet, 2016, 387(10025):1335-1346. doi: 10.1016/S0140-6736(16)00547-X pmid: 27025439
[24]	Makkapati S, D'Agati VD, Balsam L. “Green smoothie cleanse” causing acute oxalate nephropathy[J]. Am J Kidney Dis, 2018, 71(2):281-286. doi: S0272-6386(17)30863-6 pmid: 29203127
[25]	Satoskar AA, Suleiman S, Ayoub I, et al. Staphylococcus infection-associated GN-spectrum of IgA staining and prevalence of ANCA in a single-center cohort[J]. Clin J Am Soc Nephrol, 2017, 12(1):39-49.
[26]	Boils CL, Nasr SH, Walker PD, et al. Update on endocarditis-associated glomerulonephritis[J]. Kidney Int, 2015, 87(6):1241-1249. doi: 10.1038/ki.2014.424 pmid: 25607109
[27]	Chapter 9: Infection-related glomerulonephritis[J]. Kidney Int Suppl(2011), 2012, 2(2):200-208.
[28]	Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis[J]. Clin Infect Dis, 2000, 30(4):633-638. doi: 10.1086/313753 pmid: 10770721
[29]	Khneizer G, Al-Taee A, Mallick MS, et al. Chronic dietary oxalate nephropathy after intensive dietary weight loss regimen[J]. J Nephropathol, 2017, 6(3):126-129.
[30]	刘泽洲, 杨定平. IgA为主型感染相关性肾小球肾炎的研究现状[J]. 中华肾脏病杂志, 2019, 35(1): 64-69. doi: 10.3760/cma.j.issn.1001-7097.2019.01.013

IgA为主型感染相关性肾小球肾炎伴草酸盐沉积1例及文献复习

IgA-dominant infection-related glomerulonephritis with oxalate deposition: A case report and literature review

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