Fujii Takayuki, Kawamata Toyotaka, Ueda Shiro, Akikusa Bunshiro, Hasegawa Shigeru, Tsukahara Tsunemichi, Iesato Kenji, Ogawa Makoto, Saisho Hiromitsu
Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan.
Nihon Jinzo Gakkai Shi. 2003;45(8):771-7.
We experienced a coincidental case of two types of glomerulopathy associated with Graves' disease. A 64-year-old man, who had been treated with propylthiouracil(PTU) for Graves' disease for 15 years, was admitted to our hospital for macroscopic hematuria and rapidly progressive deterioration of renal function. Although his thyroid function had been within the normal range during treatment, the level of thyrotropin receptor antibody(TRAb) gradually increased from a year before admission. Serological tests revealed that he was positive for myeloperoxidase-antineutrophil cytoplasmic antibody(MPO-ANCA). The renal biopsy specimen showed necrotizing and crescentic glomerulonephritis(GN) superimposed on membranous nephropathy(MN). This is a rare case of MN complicated with ANCA associated crescentic GN in a Graves' disease patient. Association of these two renal alterations was not clearly defined. MN involved with Graves' disease also has been rarely reported. Some reports demonstrated deposition of thyroglobulin and other thyroid related antigens in the glomeruli. In the present case, long-term impairment of Graves' disease and elevation of TRAb might have been responsible for the formation and deposition of thyroid-associated immune complex in the glomeruli. As for crescentic GN, PTU might have induced ANCA-associated GN independently of MN. This case is instructive for considering the relation between Graves' disease and renal injury.
我们遇到了一例与格雷夫斯病相关的两种类型肾小球病的巧合病例。一名64岁男性，因格雷夫斯病接受丙硫氧嘧啶（PTU）治疗15年，因肉眼血尿和肾功能快速进行性恶化入院。尽管治疗期间其甲状腺功能一直处于正常范围，但促甲状腺素受体抗体（TRAb）水平自入院前一年起逐渐升高。血清学检查显示他髓过氧化物酶抗中性粒细胞胞浆抗体（MPO-ANCA）呈阳性。肾活检标本显示坏死性新月体性肾小球肾炎（GN）叠加在膜性肾病（MN）之上。这是一例格雷夫斯病患者中罕见的MN合并ANCA相关性新月体性GN的病例。这两种肾脏病变的关联尚未明确界定。与格雷夫斯病相关的MN也鲜有报道。一些报告显示甲状腺球蛋白和其他甲状腺相关抗原在肾小球中沉积。在本病例中，格雷夫斯病的长期损害和TRAb升高可能是肾小球中甲状腺相关免疫复合物形成和沉积的原因。至于新月体性GN，PTU可能独立于MN诱发了ANCA相关性GN。该病例对于思考格雷夫斯病与肾损伤之间的关系具有指导意义。
