Abstract: SA-PO362
Tubulointerstitial Nephritis and Uveitis Unmasked by Decreasing Anti-TNF Alpha
Session Information
- Genetic and Diagnostic Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 103 AKI: Mechanisms
Authors
- Tio, Maria Clarissa, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
- Cheung, Pui Susan Wen, Massachusetts General Hospital, Boston, Massachusetts, United States
Introduction
Tubulo-interstitial nephritis and uveitis (TINU) is characterized by ocular and renal manifestations, and it could be associated with autoimmune, genetic, vascular, medication, and paraneoplastic etiologies. Here we present a case of TINU unmasked by decreasing anti-TNF alpha agent adalimumab.
Case Description
55-year-old Caucasian male with history of hypertension on lisinopril and psoriatic arthritis on adalimumab admitted for acute renal failure. Four weeks prior to admission, patient presented to the ophthalmology clinic with sudden onset and progressively worsening bilateral blurring of his vision with symptomatic central vision loss. At that time, he was found to have a localized macular detachment with yellow choroidal lesions, and managed conservative with weekly follow up. Notable recent medication change was dose reduction of adalimumab from 40mg to 20mg every other week in the past year due to improvement of joint symptoms. On the day of admission at ophthalmology clinic, he was found to have an increase in retinal fluid and bilateral serous detachment with yellow/white choroidal lesions in the peripheral macula and fovea consistent with atypical uveitis. Routine labs showed sCr 12.3mg/dL (baseline 1.1 mg/dL 4 months ago), K 7.1mEq/L, HCO3- 14mEq/L, BUN 80mg/dL. Urinalysis showed 1+ leukocyte esterase, no blood or protein, urine microscopy showed WBC clumps. Despite medical management, and robust urine output, repeat K was 8.5 mEq/L required emergent hemodialysis. He was also initiated on prednisone for concerns of acute interstitial nephritis. Renal biopsy revealed acute interstitial nephritis with mononuclear cells and focal clusters of eosinophils. Other serologies showed CRP 23.7mg/L, ACE <5U/L, Lysozyme 9.9mcg/mL, ANA positive at 1:160, speckled, IgG4 negative. CT was negative for malignancy. His vision improved significantly after the first dose of prednisone. HD was discontinued on day 4 of admission, and prednisone was tapered over months. Discharge sCr was 6.76mg/dL and 2 weeks post discharge was 1.8mg/dL.
Discussion
In patient with TINU, uveitis can present as vision loss without apparent inflammation, and it often presents separately from interstitial nephritis. This patient has atypical posterior uveitis and biopsy-proven AIN consistent with TINU, likely unmasked by tapering of adalimumab.