Dear Editor,
We read with great interest the article by Bueno Filho et al. entitled “Rare association
of cutaneous vasculitis, IgA nephropathy and antiphospholipid antibody syndrome with tuberculous
lymphadenitis” that was published in the esteemed journal Clinics. The authors presented an
interesting case of cutaneous vasculitis, IgA nephropathy and antiphospholipid antibody syndrome
with tuberculous lymphadenitis in a 45-year-old woman (11. Bueno Filho R, Cordeiro AP, de Almeida FT, Shaletich C, Costa RS, Roselino AM.
Rare association of cutaneous vasculitis, IgA nephropathy and antiphospholipid antibody syndrome
with tuberculous lymphadenitis. Clinics. 2012;67(12):1497-500,
http://dx.doi.org/10.6061/clinics/2012(12)24.
http://dx.doi.org/10.6061/clinics/2012(1...
). I
would like to mention a few points regarding this paper. A definitive pathologic IgA nephropathy
diagnosis based on immunostaining assays requires the presence of dominant mesangial IgA depositions
in the absence of significant C1q depositions to rule out lupus nephritis (22. Roberts ISD, Cook HT, Troyanov S, Alpers CE, Amore A, Barratt J, et al. The
Oxford classification of IgA nephropathy: pathology definitions, correlations, and reproducibility.
Kidney Int. 2009;76(5):546-56, http://dx.doi.org/10.1038/ki.2009.168.
http://dx.doi.org/10.1038/ki.2009.168...
3. Nasri H. Comment on: Clinical, Histopathological and Immunofluorescent Findings
of IgA Nephropathy and author's reply. Iran J Immunol. 2012;
9(4):266-7.
4. Nasri H, Mortazavi M, Ghorbani A, Shahbazian H, Kheiri S, Baradaran A, et al.
Oxford-MEST classification in IgA nephropathy patients: A report from Iran. J Nephropathology.
2012;1(1):31-42, http://dx.doi.org/10.5812/jnp.7.
http://dx.doi.org/10.5812/jnp.7...
-55. Cattran DC, Coppo R, Cook HT, Feehally J, Roberts ISD, Troyanov S, et al. The
Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and
classification. Kidney Int. 2009;76(5):534-45,
http://dx.doi.org/10.1038/ki.2009.243.
http://dx.doi.org/10.1038/ki.2009.243...
), which the authors
should note. Moreover, the detection of significant fibrin deposition along with IgA deposits can
help differentiate between primary IgA nephropathy and Henoch-Schönlein purpura nephropathy
(22. Roberts ISD, Cook HT, Troyanov S, Alpers CE, Amore A, Barratt J, et al. The
Oxford classification of IgA nephropathy: pathology definitions, correlations, and reproducibility.
Kidney Int. 2009;76(5):546-56, http://dx.doi.org/10.1038/ki.2009.168.
http://dx.doi.org/10.1038/ki.2009.168...
3. Nasri H. Comment on: Clinical, Histopathological and Immunofluorescent Findings
of IgA Nephropathy and author's reply. Iran J Immunol. 2012;
9(4):266-7.
4. Nasri H, Mortazavi M, Ghorbani A, Shahbazian H, Kheiri S, Baradaran A, et al.
Oxford-MEST classification in IgA nephropathy patients: A report from Iran. J Nephropathology.
2012;1(1):31-42, http://dx.doi.org/10.5812/jnp.7.
http://dx.doi.org/10.5812/jnp.7...
-55. Cattran DC, Coppo R, Cook HT, Feehally J, Roberts ISD, Troyanov S, et al. The
Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and
classification. Kidney Int. 2009;76(5):534-45,
http://dx.doi.org/10.1038/ki.2009.243.
http://dx.doi.org/10.1038/ki.2009.243...
). Therefore, the
authors should also discuss this point. Bueno Filho et al. classified the morphologic lesions of IgA
nephropathy in renal biopsies as “focal and segmental sclerosis with mild focal and chronic
tubulointerstitial damage”. Indeed, as a result of the publication of the Oxford
classification of IgA nephropathy in 2009 (22. Roberts ISD, Cook HT, Troyanov S, Alpers CE, Amore A, Barratt J, et al. The
Oxford classification of IgA nephropathy: pathology definitions, correlations, and reproducibility.
Kidney Int. 2009;76(5):546-56, http://dx.doi.org/10.1038/ki.2009.168.
http://dx.doi.org/10.1038/ki.2009.168...
,55. Cattran DC, Coppo R, Cook HT, Feehally J, Roberts ISD, Troyanov S, et al. The
Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and
classification. Kidney Int. 2009;76(5):534-45,
http://dx.doi.org/10.1038/ki.2009.243.
http://dx.doi.org/10.1038/ki.2009.243...
), it is necessary to describe the morphologic lesions of IgA
nephropathy according to this classification system (66. Nasri H, Sajjadieh S, Mardani S, momeni A, Merikhi A, Madihi Y, et al.
Correlation of immunostaining findings with demographic data and variables of Oxford classification
in IgA nephropathy. J Nephropathology. 2013;2(3):190-5.
7. Mubarak M. Significance of immunohistochemical findings in Oxford classification
of IgA nephropathy: The need for more validation studies. J Nephropathology.
2013;2(3):210-3.-88. Mubarak M. Oxford classification of IgA nephropathy: Broadening the scope of the
classification.J Nephropathology. 2012;1(1):13-6.). Furthermore, figure 2C shows a normal glomerulus, which is in
contrast to the described morphologic features. The authors reported the final diagnosis as a
combination of tuberculous lymphadenitis, cutaneous leukocytoclastic vasculitis, primary IgA
nephropathy and anti-phospholipid antibody syndrome. However, the presence of morphologic lesions
upon renal biopsy suggests anti-phospholipid syndrome nephropathy and should have been reported
(99. Serrano F. Antiphospholipid Syndrome: A complex disease. J Nephropathology.
2013;2(1):73-4, http://dx.doi.org/10.5812/nephropathol.8999.
http://dx.doi.org/10.5812/nephropathol.8...
10. Kronbichler A, Mayer G. Renal involvement in autoimmune connective tissue
diseases. BMC Med. 2013;11:95, http://dx.doi.org/10.1186/1741-7015-11-95.
http://dx.doi.org/10.1186/1741-7015-11-9...
-1111. Nasri H. Hypertension and renal failure with right arm pulse weakness in a 65
years old man. J Nephropathology. 2012;1(3):130-3,
http://dx.doi.org/10.5812/nephropathol.8265.
http://dx.doi.org/10.5812/nephropathol.8...
).
Anti-phospholipid antibody syndrome is a vaso-occlusive disease (1212. Mardani S, Nasri H. Catastrophic antiphospholipid syndrome presenting with
sudden renal failure and past history of long-lasting psychosis and hypertension in a woman.
J Nephropathology. 2013;2(2):110-3.,1313. Mubarak M. Catastrophic antiphospholipid syndrome presenting with sudden renal
failure: The lesson lies in vascular lesions. J Nephropathology.
2013;2(2):135-8.) that affects renal tissue and has various
morphologic lesions, some of which are characteristic of the disease (1414. Sinico RA, Cavazzana I, Nuzzo M, Vianelli M, Napodano P, Scaini P, et al. Renal
involvement in primary antiphospholipid syndrome: retrospective analysis of 160 patients.
Clin J Am Soc Nephrol. 2010; 5(7):1211-7,
http://dx.doi.org/10.2215/CJN.00460110.
http://dx.doi.org/10.2215/CJN.00460110...
). Accurate documentation and reporting of such rare cases are necessary to
determine the complete spectrum of this disorder and improve the understanding of its
pathophysiology. Bueno Filho et al. merit compliments for bringing this interesting case to this
journal for discussion. Such discussions may help increase awareness of anti-phospholipid antibody
syndrome among pathologists and nephrologists, particularly in developing countries.
REFERENCES
-
1Bueno Filho R, Cordeiro AP, de Almeida FT, Shaletich C, Costa RS, Roselino AM. Rare association of cutaneous vasculitis, IgA nephropathy and antiphospholipid antibody syndrome with tuberculous lymphadenitis. Clinics. 2012;67(12):1497-500, http://dx.doi.org/10.6061/clinics/2012(12)24.
» http://dx.doi.org/10.6061/clinics/2012(12)24 -
2Roberts ISD, Cook HT, Troyanov S, Alpers CE, Amore A, Barratt J, et al. The Oxford classification of IgA nephropathy: pathology definitions, correlations, and reproducibility. Kidney Int. 2009;76(5):546-56, http://dx.doi.org/10.1038/ki.2009.168.
» http://dx.doi.org/10.1038/ki.2009.168 -
3Nasri H. Comment on: Clinical, Histopathological and Immunofluorescent Findings of IgA Nephropathy and author's reply. Iran J Immunol. 2012; 9(4):266-7.
-
4Nasri H, Mortazavi M, Ghorbani A, Shahbazian H, Kheiri S, Baradaran A, et al. Oxford-MEST classification in IgA nephropathy patients: A report from Iran. J Nephropathology. 2012;1(1):31-42, http://dx.doi.org/10.5812/jnp.7.
» http://dx.doi.org/10.5812/jnp.7 -
5Cattran DC, Coppo R, Cook HT, Feehally J, Roberts ISD, Troyanov S, et al. The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int. 2009;76(5):534-45, http://dx.doi.org/10.1038/ki.2009.243.
» http://dx.doi.org/10.1038/ki.2009.243 -
6Nasri H, Sajjadieh S, Mardani S, momeni A, Merikhi A, Madihi Y, et al. Correlation of immunostaining findings with demographic data and variables of Oxford classification in IgA nephropathy. J Nephropathology. 2013;2(3):190-5.
-
7Mubarak M. Significance of immunohistochemical findings in Oxford classification of IgA nephropathy: The need for more validation studies. J Nephropathology. 2013;2(3):210-3.
-
8Mubarak M. Oxford classification of IgA nephropathy: Broadening the scope of the classification.J Nephropathology. 2012;1(1):13-6.
-
9Serrano F. Antiphospholipid Syndrome: A complex disease. J Nephropathology. 2013;2(1):73-4, http://dx.doi.org/10.5812/nephropathol.8999.
» http://dx.doi.org/10.5812/nephropathol.8999 -
10Kronbichler A, Mayer G. Renal involvement in autoimmune connective tissue diseases. BMC Med. 2013;11:95, http://dx.doi.org/10.1186/1741-7015-11-95.
» http://dx.doi.org/10.1186/1741-7015-11-95 -
11Nasri H. Hypertension and renal failure with right arm pulse weakness in a 65 years old man. J Nephropathology. 2012;1(3):130-3, http://dx.doi.org/10.5812/nephropathol.8265.
» http://dx.doi.org/10.5812/nephropathol.8265 -
12Mardani S, Nasri H. Catastrophic antiphospholipid syndrome presenting with sudden renal failure and past history of long-lasting psychosis and hypertension in a woman. J Nephropathology. 2013;2(2):110-3.
-
13Mubarak M. Catastrophic antiphospholipid syndrome presenting with sudden renal failure: The lesson lies in vascular lesions. J Nephropathology. 2013;2(2):135-8.
-
14Sinico RA, Cavazzana I, Nuzzo M, Vianelli M, Napodano P, Scaini P, et al. Renal involvement in primary antiphospholipid syndrome: retrospective analysis of 160 patients. Clin J Am Soc Nephrol. 2010; 5(7):1211-7, http://dx.doi.org/10.2215/CJN.00460110.
» http://dx.doi.org/10.2215/CJN.00460110
Publication Dates
-
Publication in this collection
July 2013