The curious case of T-cell mediated renal allograft rejection after Covid-19 infection.

ABSTRACT: Our case illustrates the possible explanation of renal allograft rejection in a patient who had recovered from Covid-19 infection in the post-transplant period, which ultimately led to the death of the patient. A 27-year-old male patient received renal allograft from his mother, with an uneventful post-transplant period. Three years after the transplantation he contracted Covid-19 infection. The patient recovered from Covid-19 infection after being treated according to the treatment protocol. Subsequently, in the next 2 weeks, he presented with heavy proteinuria and a rise in serum creatinine level. Renal biopsy examination showed features of acute T-cell mediated rejection (TCMR) without any evidence of antibody-mediated rejection. He was given all due care but he deteriorated quickly leading to his death. This case highlights the inter-relation between Covid-19 infection and acute TCMR of the renal allograft, where renal biopsy serves as an indispensable tool in understanding its pathophysiology.

Role of light and immunofluorescence microscopy to differentiate primary and secondary membranous nephropathy.

Context: Membranous nephropathy (MN) causes nephrotic syndrome, mostly primary but may be associated with SLE, infections, cancer, or drug. Aims: To estimate clinical, serological, light microscopic, and direct immunofluorescence (DIF) findings to differentiate primary and secondary MN. Settings and Design: Prospective, cross-sectional, single-center study in a tertiary care hospital. Methods and Material: Total 51 cases from September 2019 to February 2020. Laboratory Data: Blood glucose, urine analysis, urea, creatinine, albumin, cholesterol, HBsAg, Anti HCV, ASO, ANA, MPO ANCA, PR3 ANCA, dsDNA, PLA2R, C3, and C4. Clinical parameters: age, sex, BP, skin lesions, arthralgia, edema, obesity. Renal biopsies examined with H and E, PAS, silver methanamine, MT stains. DIF done with IgG, IgM, IgA, C3c, C1q, kappa, and lambda. Statistical Analysis Used: Statistical software (Graph Pad PRISM 6) and Chi-square test). Results: Among 51 cases, 25 are primary and 26 are secondary MN with 22 being lupus nephritis, with 2 being post-infectious and the remaining 2 being proliferative glomerulonephritis with monoclonal immunoglobulin deposition (PGNMIDD) with kappa chain restriction. Mean age was 37 ± 12.18 and 30.69 ± 13.92 years for primary and secondary MN, respectively. Significant male preponderance in primary MN. Serum C4 significantly low in secondary MN (15.34 ± 9.59). Microscopic hematuria present in secondary MN. Mesangial and endocapillary hypercellularity are significant in secondary MN. IgG and kappa are significantly intense in primary whereas IgA, C3c, and C1q are significantly intense in secondary MN. Conclusions: Reliable differentiation between primary and secondary MN has important therapeutic implications.

Cutaneous Vesiculobullous Lesions: A Clinicopathologic Study.

Vesiculobullous disorders could be either immunobullous or non-immunobullous. The spectrum was analyzed using histopathology, direct immunofluorescence (DIF), and salt-split technique. Among the 104 patients analyzed, 77 (74%) were immunobullous and 25 (24%) were having non-immunobullous diseases. Bullous pemphigoid (20.2%) is the commonest among immunobullous lesions, and epidermolysis bullosa (11.5%) was the most frequent non-immunobullous lesion. Involvement of the hair and nail and a positive family history were common relationships for non-immunobullous disorders. Immunobullous lesions showed DIF positivity whereas non-immunobullous lesions were DIF negative. Perilesional DIF was more sensitive and specific than lesional DIF. The commonest antibody was immunoglobulin G (IgG) (78.9%) followed by complement 3c (C3c) (38.1%), immunoglobulin A (IgA) (25%), and immunoglobulin M (IgM) (6.6%). No lesion should be considered non-immunobullous unless both lesional and perilesional DIF results were negative.

Pediatric lupus nephritis - An evil cousin of its adult counterpart: A single-center based experience from a tertiary care hospital of Eastern India.

CONTEXT: Systemic lupus erythematosus is an autoimmune multisystem disease with a high predilection for renal involvement. Lupus nephritis develops in 20% to 75% within the first two years. Presentation varies from subnephrotic proteinuria to end-stage renal disease. AIMS: To study clinical features, biochemical, and serological parameters and correlate with histological activity and chronicity score [modified National Institute of Health (NIH) score]. SETTINGS AND DESIGN: Retrospective, cross-sectional, single-center based study in a tertiary care hospital of Eastern India. SUBJECTS AND METHODS: We incuded 36 children with lupus nephritis diagnosed from February 2018 to March 2019. Laboratory data included were complete blood count (CBC), blood glucose, urine analysis, serum urea, creatinine, blood urea nitrogen (BUN), albumin, cholesterol, HBsAg, antihepatitis C virus (HCV) antibody, antistreptolysin O (ASO) titer, antinuclear antibody (ANA), myeloperoxidase antineutrophil cytoplasmic antibody (MPO ANCA), proteinase 3 antineutrophil cytoplasmic antibody (PR3 ANCA), double-stranded DNA (dsDNA), C3, and C4. Clinical parameters were age, sex, blood pressure (BP), skin lesions, arthralgia, edema, obesity. Renal biopsies examined with light microscopy, hematoxylin and eosin (H and E), periodic acid-Schiff (PAS), silver methanamine, Masson's trichrome (MT) stains. Immunofluorescence microscopy done with IgG, IgM, IgA, C3c, C1q, kappa, lambda antibodies. STATISTICAL ANALYSIS USED: Kruskal-Wallis and χ2 tests. RESULTS: Mean age was 15.12 ± 3.49 and 12.5 ± 1.73 years for lupus nephritis (LN) with activity and LN without activity, respectively. Mean dsDNA was higher and mean C3 was lower (52.35 ± 22.21 mg/dl) in active LN. Mean 24-hour urinary protein was higher in LN without activity. Serum creatinine was raised in active LN. LN class III and IV showed higher activity than chronicity. CONCLUSIONS: Pediatric LN is proliferative and more active as compared with adult counterparts. Activity scores are much higher than chronicity scores.

Granulomatous Interstitial Nephritis - A Series of Six Cases.

Granulomatous interstitial nephritis is an uncommon variant accounting for about 6% of all tubulointerstitial nephritis. The etiology can be drugs such as antibiotics and nonsteroidal anti-inflammatory drugs and infections such as tuberculosis, sarcoidosis, and fungal infections. Renal biopsy remains the gold standard for establishing the diagnosis. Here, we present a series of six cases of granulomatous interstitial nephritis, of which two cases were associated with lupus nephritis and another two cases with crescentic glomerulonephritis. Focal segmental glomerulosclerosis and mesangiosclerosis with chronic tubulointerstitial nephritis were detected in the rest of the cases. Most of the patients presented with features of nephrotic syndrome. Urine analysis showed albuminuria in all cases. In renal biopsy, interstitial epithelioid cell granuloma was a constant feature along with which there were foci of necrosis and moderate fibrosis in few cases. But none of our cases had any relevant history of prolonged drug intake. Tuberculosis and fungal infections were also ruled out. Thereby in this case series, we subgroup all the cases into two category four cases associated with granulomatous nephritis and two cases with idiopathic granulomatous nephritis.

Correlation between Thyroid Imaging Reporting and Data System and Bethesda System of Reporting of Thyroid Cytopathology of Thyroid Nodule: A Single Center Experience.

BACKGROUND: The incidence of thyroid cancer has been increasing worldwide. Thyroid imaging reporting and data system (TIRADS) has been proposed for risk stratification of thyroid nodules to improve categorical management. Fine needle aspiration cytology based on Bethesda system for reporting of thyroid cytopathology (BSRTC) plays a fundamental role in the evaluation of thyroid nodule microscopically. Both the systems, the TIRADS and the latest revised BSRTC 2017, are widely recommended and practiced all over the world, but the correlation between the two systems has not been established. AIMS AND OBJECTIVES: This study was conducted to assess the risk of malignancy (ROM) in the intermediate Bethesda categories of thyroid lesions and their correlation with the corresponding TIRADS categories. MATERIALS AND METHOD: It was a prospective cross-sectional study over 1 year including 69 patients aged 18 years or older having solitary thyroid nodules. All cases were triaged using both TIRADS and BSRTC 2017 and the diagnostic performances were compared with subsequent paraffin sections to evaluate ROM. Correlation between TIRADS and BSRTC systems was expressed as kappa value. RESULT: Good concordance was observed between TIRADS and BSRTC systems in the evaluation of benign thyroid nodule lesions (category 2-II). There was discordance in follicular lesions (category 4-IV). The kappa value generated (0.411) revealed moderate agreement between the two risk stratification systems. CONCLUSION: Careful application of both grading systems is essential for the proper segregation of thyroid nodules to facilitate effective clinical and surgical management. However, universally acceptable protocols need to be developed to avoid the heterogeneous approach.