Wegener's granulomatosis presenting as acute suppurative interstitial nephritis

Abstract

A 78 year old man presented with acute renal failure following a prolonged respiratory illness. A renal biopsy demonstrated severe suppurative interstitial nephritis with normal glomeruli. After nine weeks of antibiotics he remained anuric and a second biopsy demonstrated pauci-immune, necrotising glomerulonephritis. His subsequent clinical course was consistent with a diagnosis of Wegener's granulomatosis and antineutrophil cytoplasmic antibodies (ANCA) were detected. This is the first reported case of Wegener's granulomatosis presenting with an isolated tubulointerstitial lesion.

Figure 1 First renal biopsy, (A) cortex and (B) medulla. (A) The glomerulus is essentially unremarkable. The surrounding interstitium is oedematous and has a chronic inflammatory infiltrate. Using morphological criteria, this comprised plasma cells, macrophages, and lymphocytes. (B) Dense aggregates of neutrophils within the lumina of tubules with the lining epithelium showing foci of degeneration and necrosis. The interstitium is oedematous and contains neutrophils and mononuclear inflammatory cells.

Figure 2 Second renal biopsy, cortex only. (A) Fibrinoid necrosis of glomerulus with an intense acute inflammatory infiltrate giving the appearance of a "micro-abscess". (B) Alcian blue/periodic acid Schiff stain showing two necrotic glomeruli with remnants of glomerular capillary wall within the inflammatory exudate.