Diffuse endocapillary proliferative glomerulonephritis and parvovirus B19 infection. A causal relationship?

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DFC: diabetic foot clinic." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alejandra Pérez-Montes de Oca, Laura Ricou Ríos, Francesc López Seguí, Núria Alonso" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Alejandra" "apellidos" => "Pérez-Montes de Oca" ] 1 => array:2 [ "nombre" => "Laura" "apellidos" => "Ricou Ríos" ] 2 => array:2 [ "nombre" => "Francesc" "apellidos" => "López Seguí" ] 3 => array:2 [ "nombre" => "Núria" "apellidos" => "Alonso" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624002638?idApp=UINPBA00004N" "url" => "/23870206/0000016300000001/v2_202407071325/S2387020624002638/v2_202407071325/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "Diffuse endocapillary proliferative glomerulonephritis and parvovirus B19 infection. A causal relationship?" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "46" "paginaFinal" => "47" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Vanesa García Chumillas, Miguel Ángel González Martínez, Mercedes Caba Molina" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Vanesa" "apellidos" => "García Chumillas" "email" => array:1 [ 0 => "vanesachumillas@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Miguel Ángel" "apellidos" => "González Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Mercedes" "apellidos" => "Caba Molina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario San Cecilio, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario San Cecilio, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Glomerulonefritis proliferativa endocapilar difusa e infección por parvovirus B19. ¿Una relación causal?" ] ] "textoCompleto" => "Parvovirus B19 (PVB19) is a commonly acquired single-stranded DNA virus, with an incidence of up to 80% in the general population.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It is associated with a wide spectrum of clinical manifestations depending on the age, haematological and immunological status of the host, such as arthropathies, red cell aplasia, hydrops and/or stillbirth, fifth disease and autoimmune diseases. Also, its association with renal disease is not well known given the limited evidence available.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>We report a case of acute endocapillary proliferative glomerulonephritis in the context of PVB19 infection in an immunocompetent patient.The patient was a 56-year-old male, with no personal history of interest, who presented with oliguria associated with polyarthritis and a self-limited febrile episode 10 days earlier. The complementary study revealed nephritic syndrome with acute renal failure (creatinine 3.2 mg/dl), microhaematuria and non-nephrotic proteinuria (800 mg/24 h) and normochromic normocytic anaemia (haemoglobin 12 mg/dl). Glomerulonephritis screening was started, highlighting hypocomplementemia (C3 49 mg/dl), autoimmune study with antinuclear neutrophil antibodies, extractable nuclear antigen, anti-neutrophil cytoplasm, anti-dsDNA, anti-glomerular basement membrane and circulating antibodies against M-type phospholipase A2 receptor in the normal range and negative infectious profile with hepatitis B virus, hepatitis C virus and human immunodeficiency virus (HIV). A renal biopsy was performed with pathological findings of diffuse endocapillary proliferative glomerulonephritis with granular deposits of C3 and immunoglobulin (Ig) G in glomerular capillaries, predominantly of a probable post-infectious nature. The serological study of possible microorganisms involved was extended, obtaining elevated IgM against PVB19 and positive polymerase chain reaction (PCR) in renal tissue.Clinical and laboratory changes during admission with diuretic treatment and volume expanders were favourable, with an adequate rate of diuresis and progressive improvement in renal function until stabilisation. Finally, the patient did not present new episodes and remained with normal renal function, without the presence of proteinuria or haematuria for 8 years after the event.Classically, viral infections (hepatitis B, C and HIV) have been associated with glomerular disease. However, the association with PVB19 is rare and poorly documented in the literature, based on case reports describing the appearance of nephritic/nephrotic syndrome after infection, without knowing its exact role in the pathogenesis of certain glomerular diseases, nor establishing a clear causal relationship.The most common clinical presentation is nephritic syndrome with hypocomplementemia following a prodrome of fever, rash or arthritis, although it can also present as nephrotic proteinuria. It has been associated with various types of glomerulonephritis such as minimal change disease, focal and segmental glomerulosclerosis, diffuse endocapillary glomerulonephritis, diffuse mesangial proliferative glomerulonephritis and collapsing glomerulopathy,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> as well as vasculitis, acute tubulointerstitial nephritis and thrombotic microangiopathy (TMA).<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Most documented cases progress to spontaneous recovery, although some present with proteinuria and/or persistent renal failure.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The choice of diagnostic tests should consider the immunological status of the patient. Serological tests are the most appropriate in immunocompetent patients, but in immunocompromised patients, anti-BPV19 antibodies are usually undetectable, and viral DNA detection by PCR is necessary.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Detection of viral DNA in renal tissue has a high positive predictive power, suggesting a direct viral effect on glomerular epithelial cells. However, different histological patterns suggest the presence of other pathogenic mechanisms involved. Viral DNA has also been shown to remain detectable in tissues such as bone marrow, synovial tissue and skin for long periods of time without evidence of disease.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>In this case, PVB19 infection was suspected after the result of the renal biopsy, presence of anaemia and compatible signs and symptoms, confirmed by serological tests, favourable course and detection of viral DNA in renal tissue.The treatment regimen depends on the immune status and severity of the infection. There is no specific antiviral therapy. Most immunocompetent patients do not require treatment. Reduction of immunosuppressive therapy and administration of immunoglobulins with a high percentage of anti-PVB19 antibodies has been shown to be effective in immunocompromised patients, although controlled studies are needed.In conclusion, PVB19 infection is a potential cause of glomerulopathy that is poorly understood. We consider it necessary to rule out acute PVB19 infection in the presence of nephrotic/nephritic syndrome or atypical presentation of TMA, especially if it occurs in an epidemic context or is associated with viral syndrome or non-regenerative anaemia. It is also important to note that the detection of viral DNA in different tissues does not necessarily indicate active infection and should be interpreted with caution. Therefore, further studies are needed to define the exact role of PVB19 in kidney disease and to improve the therapeutic approach, especially in immunocompromised patients.Ethical considerationsThe authors declare that they have followed the protocols established in their work centre for accessing the patient's clinical history data in order to be able to make this publication available to the scientific community.FundingThe authors received no funding for this article.Conflict of interestThe authors declare that they have no conflicts of interest." 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