Kenar JhaveriHofstra North Shore LIJ School of Medicine

March 2011A case based approach

Goals Present case/clues with pictures, YOU GUESS THE VIRUS

Then we discuss how it effects the kidney

Case 1: 40 year old male, past IV Drug abuse

Image Courtesy: uncnephropathology.org

Labs show Crt up from 0.7 to 4.0mg/dl and protein/crt ratio 15gm

Image source: flickr.com

Patient has night sweats, weight loss and temporal wasting.Normo-tensive on exam and no edema on exam.

DiagnosisHIV associated Collapsing

FSGS or HIVAN

HIV is a RNA retrovirus

Case 2: Same patient, only difference:- He plays cricket for the West IndiesTeam nationally.

DiagnosisHTLV-1 Associated Collapsing FSGSThink HIV like disease but virus is HTLV-1

Other findings:T cell LeukemiaHypercalcemia

HTLV-1 is also a RNA retrovirus

Case 3: 54 y old male with 5 years post DDRTx( thymo, steroids +, triple drug regimen)

P/Crt ratio 7gm, crt slowly rising, anemia, thrombocytopenia, night sweatsHe does mention that the other day, his son “slapped” his cheeks.

Courtesy: indianjnephrol.org 2011

What if I changed the patient to either a child with this picture or a Sickle Cell Patient with proteinuria?

DiagnosisParvoVirus B19 associated Collapsing FSGS

Renal diseaseCollapsing GloemrulopathyCystitis

PB19 is a single stranded DNA virus

Case 4: 32 y old male with subnephrotic proteinuria, crt 1.3mg/dl now to 1.6History of HIV on HAART. History of IV Drug abuse

Image Courtesy:renalfellow.blogspot.com

UA showed 1-2+ RBC's/hpf. Serum albumin was 3.7 g/dL and serum cholesterol 209 mg/dL.  All serologies were negative or normal, But C3 and C4 are low.

pmj.bmj.com

RF is 400( elevated), IF shows strong C3 and IgM andModerate IgG and negative IgA

Image Source: uninet.edu

60nm

DiagnosisHepatitis C associated

Cryoglobulenemic Nephritis( MPGN)

Hep C virus is single stranded RNA virus

Hepatitis C and the kidneySerum antihepatitis C virus antibodySerum hepatitis C virus RNA by polymerase

chain reactionElevated serum aminotransferasesCryoglobulinemia (mixed type II with

monoclonal immunoglobulin M kappa)Cryocrit (2%–70%)Low C4, C1q, CH50Normal or only slightly low C3

Case 5: 76 y old male with ALL with Allogenic Stem Cell transplant develops hematuriaOn Day +60

Image source: tpis1.upmc.com

Leukopenia along with a sudden rise in crt noted from 1- 3mg/dl

Image Source: emedicine.medscape.com

Developed blurry vision as well- Ophthamology made the diagnosis Before you!

Image Source: emedicine.medscape.com

DiagnosisCMV Nephritis, along with Retinitis

Renal disease Tubular interstitial DiseaseFSGS, proliferative GNTMAUreteritisHemorrhagic cystitis

CMV is part of the Herpes Viruses (DNA virus)

Case 6: 67 y old LRRTx and recent admission for rejection now comes With hematuria and AKI

Image Source: NKF 2001 and renalfellow.blogspot.com

http://www.ndt-educational.org/

You look in the urine and find these!

pathology2.jhu.edu

DiagnosisBK Nephropathy

DNA virus

Case 7: 56 y old male presents with proteinuria of 2.5gm and slowly rising crtOver 2-3 weeks. He has also noticed that he has worsening neuropathy and edema Over past months

flickr.com

On exam, he has an enlarged spleen, liver and inguinal lymph nodes andYou confirm peripheral neuropathy and 2+ edema. BP is elevated at 145/90

nature.com

Patient has monoclonal gammopathy on labs noted on serum free light chains,Over 2 weeks, patients develops hyperpigmented skin as well. SH: patient is from sub Sahara in Africa

biol4634.wordpress.com

DiagnosisHHV-8 associated Thrombotic

MicroangiopathyKaposi SarcomaLikely POEMS Syndrome

HHV8 is part of the Herpes DNA viruses

Case 8: 17 y old male has a cough and soar throat. His girlfriend was sick Recently as well

kidneypathology.com

You do a detailed HEENT exam and find this?

Ig A

unckidneycenter.org

If this was a post kidney transplant patient, this virus can also causeLymphoma!

flickr.com

DiagnosisEBV associated Ig A Nephropathy

EBV- Ig A Nephropathy, Proliferative GNEBV – Burkitt’s LymphomaEBV- PTLD

EBV is part of the herpes DNA viruses

Case 8: A 56 y old female has 13gm of proteinuria. She is a physicianShe had a femoral stick exposure few years prior

medicinembbs.blogspot.com

Complements are normal. On IF, shows IgG1,2 or 3

pathguy.com

Her antibodies to the human phospholipaseA2 receptor (PLA2R) are negative

Also, her LFTs are elevated

DiagnosisHep B associated Membranous GN

Hep B is a double Stranded DNA virus

Case 9: 14 y old boy presents with fever and a rash. The illness resolves But few days later, there is acute rise in crt and hematuria.

gamewood.net

The electron microscopy showed this finding:- In idiopathic variant of this disease, it can be treated with anti complement agents

www1.imperial.ac.uk

DiagnosisMeasles associated Dense Deposit Disease

Usually associated with a form of immune complex disease, proliferative GN or dense deposit disease

Paramyxovirus causes Measles is a single stranded RNA virus

Case 10. What if the boy had similar findings, but had pancreatitis as wellOn exam you noticed parotid swelling

Ig Akidneypathology.com

DiagnosisMumps Associated Ig A Nephropathy

Mumps – immune complex GN and Ig A Nephropathy

Mumps caused by paramyxovirus – RNA virus

Case 11. A 45 y old male with myeloma gets an allogenic stem cell transplant15 days following, has gross hematuria and rise in crt

Virus in the bone

ndtplus.oxfordjournals.org

This virus can also cause gastroenteritis and croup

tedpella.com

kidneypathology.com

DiagnosisAdenovirus Nephritis

Renal disease: Tubular Interstitial Disease( usually

necrotizing)Hemorrhagic Cystitis

Adenovirus is a DNA virus

Case 12: A 23 y old male in the CCU admitted for viral myocarditis has acute Rise in crt, and hematuria

kidneypathology.com

Patient also develops aseptic meningitis, urine has blood, no RBCS

kidneypathology.com

DiagnosisCoxsackie B associated Renal disease- here

secondary to Rhabdomyolysis

RhabdomyolysisIg A nephropathy

Cox B is a Rna virus

What other common virus can lead toRhabdo associated renal disease?

Influenza A

Trends- Interstitial Diseases:- CMV, Adenovirus, HIV,

BKV- TMA: CMV, HHV8 and HIV- Rest all- Glomerular Diseases

Future DirectionsNIH has embarked on a program to identify viral causes of unexplained renal Diseases- focus on collapsing FSGS, and Thrombotic microangiopathy

Use of a customized array of 655 viruses from 135 genera to be used.

Waldman M, Kopp J. Virues and Kidney disease: Beyond HIV. Semin Nephrol 2008:28:6:595-607.