Renal failure resulting from infiltration by inflammatory myofibroblastic tumor responsive to corticosteroid therapy.

Inflammatory myofibroblastic tumor (IMT) is a rare disease of inflammatory and spindle cell proliferative lesions in multiple sites. Most frequently reported in the lungs, a variety of extrapulmonary sites have been described. We report the first case of IMT causing renal failure by massive bilateral renal infiltration. Renal function continued to deteriorate (peak serum creatinine level, 8.4 mg/dL) despite placement of a ureteral stent. The kidneys were diffusely enlarged on computed tomographic (CT) scan. Renal biopsy showed myofibroblastic proliferation and inflammatory infiltration. Renal failure responded favorably over weeks to corticosteroid therapy (serum creatinine level, 2.8 mg/dL) with a marked reduction in bilateral renal enlargement by CT scan.

Correlation of clinical outcomes after tacrolimus conversion for resistant kidney rejection or cyclosporine toxicity with pathologic staging by the Banff criteria.

BACKGROUND: Refractory rejection and cyclosporine (CsA)-induced nephropathy remain important causes of renal allograft loss. Previous studies demonstrated that 70-85% of the episodes of refractory acute rejection (AR) occurring in renal allograft recipients on a CsA-based immunosuppressive regimen could be salvaged by conversion to tacrolimus. No data are available regarding the correlation between allograft histology at the time of conversion and the response to tacrolimus. We examined the response to tacrolimus conversion in relation to preconversion biopsies stratified by the Banff criteria. METHODS: Since May 1992, we have converted 22 patients from CsA to tacrolimus as part of a rescue protocol. We report on 18 patients in whom 6-month follow-up was available after conversion for biopsy-proven AR (n=13) or CsA toxicity (n=5). Sixteen patients were recipients of renal allografts, including three second transplants, and two were recipients of kidney-pancreas transplants. All patients with AR were treated with one or more courses of methylprednisolone and OKT3 before conversion. Renal allograft biopsies were interpreted by a transplant pathologist blinded to the clinical history, and graded according to the Banff criteria. Responses to tacrolimus were scored as improved (creatinine returned to within 150% of baseline), stabilized (creatinine rise arrested), or failed (returned to dialysis). RESULTS; Mean follow-up was 17.3+/-8 months. Fourteen of 18 patients (78%) showed improvement or stabilization in renal function as assessed by creatinine at 6 months or 1 year (when available). Of the 13 patients with histological AR, nine (69%) improved, including five of six with borderline AR, two of three with grade I AR, and two of four with grade II AR. Of the four other patients with AR, two stabilized and two failed. Three of five patients with severe clinical rejection requiring dialysis (range 2-16 weeks) recovered renal function after conversion. Of five patients with CsA toxicity, two (40%) improved. Seven of eight patients who were converted to tacrolimus less than 90 days after transplantation improved, compared with only 4 of 10 who were converted more than 90 days after transplantation. No grafts were lost in patients with a creatinine <3.0 mg/dl at the time of conversion versus two of seven grafts lost when the creatinine was 3.1-5.0 mg/dl and two of eight grafts lost when the creatinine was >5.0 mg/dl. CONCLUSION: The majority of steroid and antilymphocyte antibody (OKT3 or ATGAM) unresponsive rejections in patients on CsA-based immunosuppression will improve or stabilize after conversion to tacrolimus. There was no correlation with allograft histology stratified by the Banff criteria and the response to tacrolimus. Although there was a trend toward a poorer response with more severe histological rejection, higher serum creatinine at the time of conversion, and longer time from transplantation to conversion, favorable responses were noted in all groups. This indicates that a trial of conversion is warranted, irrespective of the histological severity of injury.

Late renal allograft failure secondary to thrombotic microangiopathy associated with disseminated malignancy.

A renal transplant recipient with a remote history of end-stage renal disease due to postpartum hemolytic-uremic syndrome (HUS) presented with acute renal failure after having stable renal allograft function for 9 years. A diagnosis of thrombotic microangiopathy was made based on clinical and histologic findings at renal biopsy. She was treated conservatively, never regaining graft function and ultimately succumbing from her overwhelming tumor load approximately 6 months following diagnosis of her malignancy. To our knowledge, this is the first report of thrombotic microangiopathy associated with disseminated malignancy resulting in renal allograft failure.

Epstein-Barr virus-induced infectious mononucleosis complicated by acute renal failure: case report and review.

Infectious mononucleosis, most commonly caused by Epstein-Barr virus (EBV), is generally a benign, self-limited illness. Occasionally, however, more severe complications may arise such as acute renal insufficiency. While subclinical renal involvement appears to be relatively common in patients with infectious mononucleosis, patients with significant renal parenchymal dysfunction have rarely been described in the English-language literature. In this report, we review 27 previous cases ad present a case of oliguric renal failure complicating heterophil-positive infectious mononucleosis. The patient required hemodialysis but recovered promptly with treatment with the combination of corticosteroids plus acyclovir. Renal biopsy revealed interstitial nephritis, and immunoperoxidase studies demonstrated a predominance of suppressor/cytotoxic T cells, which has been described in only one previous case report. In situ hybridization done on renal biopsy tissue failed to reveal evidence of EBV-encoded RNA-1. Acute renal failure in infectious mononucleosis is rare, often self-limited, and usually caused by interstitial nephritis that is likely the result of immunopathologic injury precipitated by EBV infection.

Paget's disease of the nipple and angiosarcoma of the breast following excision and radiation therapy for carcinoma of the breast.

We report a case of bilateral angiosarcomas developing in breasts after radiation therapy. The angiosarcomas developed 7 years after the first dose and 3 years after the last dose of radiation. In addition, Paget's disease of the nipple was diagnosed in the right breast. c-neu overexpression was noted in the adenocarcinoma but not in the angiosarcoma. Neither tumor was immunoreactive for c-k-ras. The oncogenic expression of the radiation-induced angiosarcoma was different from that of the radiation-resistant adenocarcinoma. The simultaneous occurrence of angiosarcoma and Paget's disease of the nipple has not been reported previously. The importance of recognizing Paget's disease in post-irradiated breasts and complications of breast conservation therapy are stressed.

Aggravation of diabetic nephropathy by lithium: a case report and review of the literature.

A manic-depressive diabetic man receiving lithium carbonate therapy had massive proteinuria, which dramatically improved after the withdrawal of lithium. The authors discuss previous cases of lithium-induced nephrotic syndrome in nondiabetics and draw attention to the possibility that lithium therapy aggravates protein excretion in diabetic patients.

Age at first birth and breast atypia.

The relation between age at first birth and the occurrence of fibrocystic breast disease of different atypia subtypes was evaluated using data from a cohort study of the health effects of oral-contraceptive use. Multivariate case-control analysis was performed on 218 parous women with biopsied fibrocystic disease and 928 parous controls. Fibrocystic breast disease, as a whole and as atypia subtypes, was found to be unrelated to age at first birth. Furthermore, the estimated effect of age at first birth did not vary from one atypia subtype to another. Women with high parity were found to be at decreased risk of fibrocystic breast disease compared to those with low parity. Age at completion of education, used as an indicator of socioeconomic status, was found to be moderately associated with fibrocystic breast disease. The estimated effect of parity and age at completion of education also did not vary among subtypes. More epidemiologic studies specific to histopathologic classifications of benign breast disease are called for.

Oral contraceptive use and fibrocystic breast disease of different histologic classifications.

The relationship between oral contraceptive (OC) use and occurrence of fibrocystic breast disease (FBD) of different histologic classifications was evaluated with data from a cohort study. Biopsy specimens from 232 women with FBD were classified into different atypia categories. In 96 matched pairs of OC users and nonusers, atypia scores were lower in users than in nonusers. Women without breast diseases (500 OC users and 500 nonusers) were sampled from the original cohort to form a two-stage "anamorphic" study with the 232 cases of FBD. The previously shown inverse association between OC use and FBD occurrence was present and increased with increased length of OC use. However, the "protective effect" of OC use did not vary for different histologic classifications of FBD. The findings from both paired and anamorphic analyses of the data are not consistent with the hypothesis that the use of OC is associated with decreased frequency only of FBD with minimal epithelial atypia.

Peripheral hepatic artery embolization for primary and secondary hepatic neoplasms.

Eighteen patients underwent peripheral arterial embolization with Gelfoam powder for treatment of primary or metastatic hepatic neoplasms. Except for two cases in which the patients could not undergo long-term arterial infusion, all cases were treatment failures from intravenous chemotherapy, intra-arterial chemotherapy, or, in some cases, intra-arterial chemotherapy plus radiation therapy. Fourteen patients had good symptomatic relief from the procedure. Four of these patients are alive at 3, 5, 6, and 18 months following the procedure. Four patients died within 2 weeks following embolization, three of progression of disease and one of aspiration pneumonia. Of the patients showing symptomatic relief, 10 died of progression of cancer 2 to 14 months following embolization, with a median survival of 5 months. Based on the results in this small group of patients, it would seem that transcatheter hepatic dearterialization is often successful palliative therapy in patients who are not responsive to traditional therapies. Because of the low procedural morbidity, transcatheter embolization is superior to surgical dearterialization.

Riedel's struma associated with subacute thyroiditis, hypothyroidism, and hypoparathyroidism.

Riedel's struma with dense fibrous invasion of surrounding muscle and fat was found in a patient who had clinical subacute thyroiditis superimposed on primary hypothyroidism. Riedel's struma may sometimes be an uncommon stage in the more common subacute form of thyroiditis, although in our patient an unusual coincidence of subacute thyroiditis and Riedel's struma is also possible. Of interest in our patient was the development of spontaneous primary hypoparathyroidism; parathyroid function returned to normal concomitant with the spontaneous resolution of the goiter after partial resection. This patient also represents another instance of hyperthyroidism developing in a previously hypothyroid patient.