ANATOMIC PATHOLOGY
Single Case Report
Coexistence of Anti-Neutrophil Cytoplasmic
Antibody-Associated Glomerulonephritis
and Membranous Glomerulopathy
LILLIAN W. GABER, M.D., 1 BARRY M. WALL, M.D., 2 AND C. ROBERT COOKE, M.D. 2
The association of renal Wegener's granulomatosis with other
glomerular diseases is very rare. A case of anti-neutrophil cytoplasmic antibody-associated necrotizing glomerulonephritis
superimposed on a membranous glomerulopathy in a patient with
systemic Wegener's granulomatosis is reported. Renal failure
was corrected by immunosuppressive therapy treatment, but a
non-nephrotic-range proteinuria persisted for several months.
The association of membranous glomerulopathy with anti-glo-
merular basement membrane disease and other autoimmune diseases is well described; however, anti-neutrophil cytoplasmic
antibody-associated vasculitis superimposed on membranous
glomerulopathy has not been reported previously. (Key words:
Wegener's granulomatosis; Membranous glomerulonephritis;
Anti-neutrophil cytoplasmic auto antibody-associated glomerulonephritis) Am J Clin Pathol 1993; 99:211-215
Wegener's granulomatosis (WG) is typically characterized
by necrotizing or granulomatous vasculitis involving the
upper and lower respiratory airways and the kidneys.
Kidney involvement occurs in 85% of patients during active exacerbations, which are almost invariably preceded
by extrarenal manifestations of the disease.' Focal and
segmental necrotizing glomerulonephritis with paucity of
immune complexes is the most commonly described renal
lesion in patients with active WG. 2 Except for a single
case reported by Wahls and others3 that described the
emergence of anti-glomerular basement membrane disease in a patient with pulmonary limited Wegener's granulomatosis, no other renal diseases have been described
that coexist with the typical renal lesions of WG. We report the histopathologic and immunologic findings in a
patient with classic systemic WG whose renal disease
manifested as a necrotizing glomerulonephritis with
thrombosis, crescent formation, and membranous
glomerulopathy (MGN).
CASE REPORT
A 64-year-old, previously healthy man experienced episodes of recurrent sinusitis during a 1 -year period. Three months before admission,
he developed refractory otitis media that required therapy with antibiotics
and bilateral placement of pressure-equalizing tubes. He also reported
the recent onset of episodic fever, a cough producing blood-streaked
sputum, dyspnea on exertion, and a 20-pound weight loss. The patient
denied any prior history of edema of the extremities, renal disease, or
hypertension. Pertinentfindingsafter admission to the hospital included
a body temperature of 99° F, with episodic spikes to 101° F. Blood
pressure was measured at 160/90 mmHg. Shallow ulcerations with bloody
exudate were present in both anterior nares. Diffuse rhonchi were heard
posteriorly in both lung fields. Findings from the rest of the physical
examination were within normal limits. Pertinent laboratory findings
included a hematocrit concentration of 31% and white blood cell count
of 10,3O0/mm3. The erythrocyte sedimentation rate was 120 mm/hr.
Results of urinalysis were 2+ positive for protein and 4+ positive for
blood, with too many dysmorphic red blood cells in the urinary sediment
to count. The serum creatinine concentration, which was 141.4 mmol/
L on admission, increased in less than 1 week to 300.56 mmol/L. A 24hour urine collection specimen contained 1.6 g protein. Tests results for
anti-nuclear antibodies, rheumatoid factor, and serum complement levels
were negative or normal. A test for serum anti-neutrophil cytoplasmic
antibody (ANCA) was positive at a titer greater than 1:320. Anti-neuFrom the 'Department of Pathology, University of Tennessee, and the trophil cytoplasmic antibody, detected by indirect immunofluorescent
1
microscopic examination of alcohol-fixed cells, was present at a titer of
Department of Medicine (Nephrology), Veterans Administration Medical
1:320 dilutions in a cytoplasmic pattern. The perinuclear pattern was
Center, Memphis, Tennessee.
not identified. Chest radiograph revealed a left hilar mass and a second
mass in the left posterior lungfield.Bronchoscopy revealed hemorrhagic
Received November 8, 1991; revised manuscript accepted for publication March 23, 1992.
mucosa in multiple segmental airways. Multiple biopsy specimens taken
Address reprint requests to Lillian W. Gaber: Department of Pathology,
at the time of bronchoscopy showed acute capillaritis and granulomatous
University of Tennessee-Memphis, 800 Madison Avenue, Memphis,
inflammation of the pulmonary parenchyma. Results of special stains
Tennessee 38163.
211
212
ANATOMIC PATHOLOGY
Single C
for acid fast bacilli and fungi were negative. A percutaneous renal biopsy
was performed. Systemic Wegener's granulomatosis was diagnosed on
the basis of the clinical and histopathologic findings. Treatment with
orally administered cyclophosphamide (2 mg/kg/day) and prednisone
(60 mg/day) was begun. The cyclophosphamide dose was subsequently
reduced to 1 mg/kg/day because of refractory anemia. Because of the
severity of the anemia, the patient received cyclophosphamide for only
3 months. Prednisone administration was continued at 40 to 60 mg/
day. The patient's otorrhea, rhinorrhea, cough, and dyspnea rapidly
cleared. The previously noted masses on chest radiographs resolved within
a 3-month period. Microscopic hematuria also resolved and serum creatinine concentration decreased to 141.4 mmol/L. Three months after
institution of therapy, test results for ANCA were negative. The patient's
prednisone dose subsequently was slowly tapered to a maintenance dose
of 7.5 mg/day, with no evidence of relapse of WG. Despite sustained
remission and a stable renal function, the 24-hour urine collection specimen contained 1.5 g protein on several occasions. Proteinuria eventually
resolved 22 months after the acute onset of WG.
MATERIALS A N D METHODS
Tissue for light microscopic examination was fixed in
phosphate-buffered formaldehyde (Carson's Milloning's
fixative) and embedded in historesin. Three-micrometerthick serial sections were stained with hematoxylin and
eosin, periodic acid-Schiff, and periodic acid-methenamine silver. Sections of frozen biopsy material were
stained with fluoresceinated antibodies to IgG, IgM, IgA,
C3, Clq, properdin, fibrin-reactive products, and light
chains, according to standard direct immunofluorescence
techniques. Tissue for electron microscopic examination
was fixed in Carson's fixative, postfixed in osmium tetroxide, and embedded in spurr. Selected blocks were thin
sectioned and stained with lead citrate and uranyl acetate.
RENAL BIOPSY RESULTS
Light Microscopic Findings
The biopsy contained 19 glomeruli. In 11 glomeruli
(58%), large segments of the glomerular tufts showed extensive acute fibrinoid necrosis without intracapillary cellular proliferation (Fig. 1). Disruption of the peripheral
glomerular basement membranes and intracapillary
thrombosis was noted in the necrotic glomerular segments
and in adjacent capillary loops. Fibrin extended from the
injured loops into Bowman's space. Proliferation of the
glomerular parietal epithelial cells was observed surrounding necrotic segments and resulted in the formation
of large cellular crescents in two glomeruli. Silver-stained
sections demonstrated a prominent diffuse "spike pattern"
along the glomerular basement membranes. Red blood
cells and hyaline casts were noted in the tubules. A mixed
population of leukocytes, particularly lymphocytes and
eosinophils, was present in the interstitium. This interA.J.C.P. •
Report
stitial reaction was associated with a low-grade tubulitis
characterized by the presence of lymphocytes interposed
between tubular epithelial cells and tubular basement
membranes.
Immunofluorescence
Findings
Immunofluorescence studies revealed that all glomeruli
had a generalized 4+ (scale, 0-4+) granular fluorescence
with anti-IgG and kappa and lambda light chains, along
the peripheral glomerular capillaries (Fig. 2). Glomerular
staining for fibrin-reactive products was segmental and
focal in distribution. There was no staining with labeled
sera directed against IgA, IgM, C3, Clq, and properdin.
Electron Microscopic Findings
Many subepithelial, electron-dense deposits were present, many incorporated within the glomerular basement
membrane as a result of the reactive formation and deposition of new basement membrane material around
these deposits. Electron-lucent deposits or evidence of
basement membrane repair was not seen. The lamina
densa was intact within most capillary loops. The epithelial cells displayed diffuse effacement of the foot processes
and many microvillous projections. A single loop exhibited a break in the peripheral capillary wall associated
with intravascular fibrin deposition (Fig. 3). Neither mesangial nor subendothelial electron-dense deposits were
identified.
DISCUSSION
The patient described in this report had the typical
stigmata of WG, including upper respiratory tract involvement, multiple pulmonary nodules, and renal insufficiency with histologic evidence of pulmonary
granulomatous vasculitis, segmental necrotizing glomerulonephritis, and a high serum titer of ANCA. The patient
responded appropriately to immunosuppressive treatment, and ANCA levels decreased as the disease became
quiescent. In addition to the characteristic WG renal lesions, a membranous glomerulopathy was identified consistent with a double glomerulonephritis.
Wegener's granulomatosis, Goodpasture's syndrome,
and systemic vasculitis (including polyarteritis nodosa and
microscopic polyarteritis) are causes of a pulmonary-renal
syndrome. In WG, the respiratory symptoms usually precede renal involvement by weeks to years.1 The typical
renal injury in WG is characterized by segmental necrotizing glomerulonephritis, with progressive crescentic
proliferation of the glomerular epithelium producing rapidly progressive renal failure.2'4 Granulomatous glomerulonephritis is an infrequent finding, even in autopsy series
uary 1993
GABER, WALL, AND COOKE
213
Double Glomerulonephritis in Wegener's Granulomatosis
FlG. 1 (upper). Segmental fibrinoid necrosis of the glomerular tuft with proliferation of the glomerular epithelium, disruption of
Bowman's capsule, and extension of the necrosis into
the interstitium (silver methenamine, X400).
FIG. 2 (lower). Direct immunofluorescence microscopy demonstrating many
granular deposits along the
subepithelial surface of the
glomerular basement membrane (fluorescein-conjugated anti-lgG, X400).
^t<.
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%*w
>*
if*
%j^g^
in which ample sampling of the diseased kidneys is possible. The granulomatous inflammation develops only in
severe cases with widely distributed necrosis of the glomerular capillary tufts, thrombosis, and crescent forma-
.^ri
tion. Cases with severe necrotizing granulomatous glomerulonephritis may be accompanied by fibrinoid necrosis of the hilar arterioles and vasa recta.5 Renal papillary
necrosis is a rare complication possibly caused by massive
Vol. 99 • No. 2
214
ANATOMIC PATHOLOGY
Single
FlG. 3. Electron micrograph of a distorted segment of the glomerular
tuft illustrating the combination of membranous glomerulopathy and
glomerular necrosis. The thickened capillary loop in the upper left corner
contains subepithelial and intramembranous electron-dense deposits
characteristic of Stage II-III membranous glomerulopathy. The necrotic
capillaries (arrow) display evidence of the membranous lesions despite
the collapse and the dissolution of the basement membrane (lead citrate
and uranyl acetate, X8,700).
vasculitis of the vasa recta.6 Acute vasculitis involving the
larger interlobular arteries also has been described; however, in most cases of WG the vasculitis within the kidney
is usually sparse, focal, and limited to the intima. 78
Most histopathologic studies of renal tissue from patients with WG have failed to demonstrate significant immune complex deposition. Subepithelial, mesangial, intramembranous, or subendothelial deposits have been
described in only a small percentage of renal biopsy specimens obtained from patients with active disease.2 The
deposits have usually been nonspecific, few in number,
demonstrable only by electron microscopic examination,
and not substantiated by immunofluorescence examination of the tissue.9 Immunoglobulin M and fibrin, however, have been noted frequently in necrotic glomeruli.2
Furthermore, renal WG is distinguished from most other
causes of necrotizing glomerulonephritis by the paucity
of glomerular immune complex deposits and by the absence of anti-glomerular basement membrane antibodies
(GBM) antibodies.
Immunologic testing for the presence of anti-GBM antibodies or ANCA is essential in determining the cause
of pulmonary-renal syndromes. Anti-neutrophil cytoplasmic antibody levels are typically elevated in patients
with active Wegener's granulomatosis, polyarteritis nodosa, and microscopic polyarteritis and are consistently
negative in patients with Goodpasture's syndrome or antiGBM disease.10 Overlap of diseases causing pulmonary-
A.J.C.P. •
Report
renal syndrome is an infrequently described occurrence
that further complicates the clinical and pathologic results.
Wahls and associates3 described the emergence of antiGBM disease in a patient with typical limited pulmonary
granulomatous WG. Kondo and others'' provided a detailed analysis of the autopsy findings of a patient with a
fatal pulmonary-renal syndrome caused by both a systemic necrotizing small vessel arteritis and Goodpasture's
syndrome with antibodies reactive to both glomerular and
alveolar basement membranes.
The occurrence of double glomerulonephritis, as illustrated in this case report, is very infrequent.12 In approximately two thirds of the cases, diabetic glomerulosclerosis
is one of the concomitant glomerular lesions.12 Membranous glomerulopathy is also commonly implicated in
double glomerulonephritis. Diabetic glomerulosclerosis,
anti-GBM glomerulonephritis, crescentic glomerulonephritis, IgA nephropathy, and post-streptococcal glomerulonephritis have developed in patients with preexisting
membranous nephropathy. 13 More than 13 cases have
been reported in the literature illustrating the transformation of membranous glomerulopathy into crescentic
glomerulonephritis. I4~19 Approximately one half of the
reported patients had evidence of anti-GBM antibodies
at the time of transformation. It has been postulated that
the presence of epimembranous and intramembranous
immune complexes and the associated reactive changes
in the glomerular basement membrane alter the biochemical and the antigenic properties of the glomerular
basement membrane, thus initiating the development of
a secondary form of anti-GBM disease. Other patients
developed crescentic glomerulonephritis superimposed on
an established biopsy-proved MGN, without evidence of
anti-GBM antibodies. I819 Crescentic glomerulonephritis
in these patients often was preceded by a viral syndrome.
There was no evidence of systemic vasculitis and the vascular injury was limited to the kidney. Anti-neutrophil
cytoplasmic antibody levels were not available at the time
of reporting.
In our patient, the ANCA-positive, anti-GBM-negative
necrotizing glomerulonephritis was the last manifestation
of the typical triad of organ involvement in WG. The
patient had been symptomatic with upper and lower respiratory disease for at least 6 to 12 months. In contrast,
the duration of his membranous glomerulopathy was not
clear because no urinalysis was available before admission
to the hospital. On the other hand, the disappearance of
the proteinuria 1 year after the resolution of WG indicates
spontaneous remission of MGN. Less than one third of
the patients with idiopathic MGN experience remission,
even without therapy.
This concomitant occurrence of MGN and renal WG
in our patient may be coincidental; a causal relationship
iary 1993
GABER, WALL, AND COOKE
215
Double Glomerulonephritis iiWegener's Granulomatosis
between the two diseases needs to be explored. Immune
mechanisms involved in the development of either renal
lesion differ. In situ formation of immune complexes,
induced by the presence of implanted or endogenous antigens in the glomerular basement membrane, leads to
the development of MGN. 20 In WG, the tissue destruction
is directly produced by lytic enzymes and other products
of the primary granules of damaged neutrophils.21 Several
autoimmune diseases, such as systemic lupus erythematosus, Hashimoto's thyroiditis, and mixed connective tissue disease,22 have been known to coexist with membranous glomerulopathy. It is possible that these patients have
underlying defect(s) in their immune system that precipitate the emergence of a combined membranous glomerulopathy and autoimmune diseases. Van der Woude and
colleagues23 provided evidence to support the presence of
an abnormal reticuloendothelial function in patients with
active systemic lupus erythematosus, active Wegener's
granulomatosis, and membranous glomerulopathy.
9.
10.
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