Department of Rheumatology, Allergy and Clinical Immunology, National Hospital Organization Chibahigashi National Hospital, 673 Nitona-cho, Chuou-ku, Chiba City, Chiba, 260-8712, Japan.
Laboratory of Autoimmune diseases, Department of Clinical Research, National Hospital Organization Chibahigashi National Hospital, Chiba City, Chiba, 260-8712, Japan.
J Med Case Rep. 2021 Sep 23;15(1):482. doi: 10.1186/s13256-021-02909-z.
Tubulointerstitial nephritis and uveitis syndrome is a rare lymphocyte-related oculorenal inflammatory disease presumed to be associated with drug use and infectious agents. Toxoplasma gondii is one of such pathogens that could exhibit encephalitis, meningitis, and uveitis in immunocompromised or in some immunocompetent individuals. If the immunoglobulin M of Toxoplasma is positive on screening, the interpretation of the result is not simple, especially when immunoglobulin M stays positive persistently.
A 34-year-old Asian male developed fever, headache, and lymphadenopathy with tenderness, which was initially diagnosed as meningitis. Antibiotics were started, and diclofenac sodium was used for the fever. Although his symptoms were alleviated in a week by the treatment, gradual decline in renal function was noted, prompting a renal biopsy that indicated acute granulomatous interstitial nephritis. A week later, tenderness in both eyes with blurred vision appeared and revealed iritis and keratic precipitations in both eyes; hence, the diagnosis of acute tubulointerstitial nephritis and bilateral uveitis syndrome was made. Toxoplasma gondii-specific immunoglobulin G and immunoglobulin M titers were both positive. Although we could not rule out recent infection of Toxoplasma gondii, which may cause uveitis initially, Toxoplasma immunoglobulin G avidity test indicated a distant infection, which allowed us to rule out meningitis and uveitis as responsible for the complication of recent Toxoplasma gondii infection. Drug-induced lymphocyte stimulation test, or lymphocyte transformation test of diclofenac sodium, was solely positive among the tested drugs. Uveitis was alleviated only with ophthalmic steroid, and renal function returned to normal without administration of systemic steroid.
We experienced a case of diclofenac-induced tubulointerstitial nephritis and uveitis syndrome. In ruling out infections, Toxoplasma immunoglobulin M was persistently positive, and Toxoplasma immunoglobulin G avidity test indicated a "distant" infection. From these two results, we ruled out recent infection. However, it should be noted that "distant" infection indicated by commercial immunoglobulin G avidity is still a multiplex profile consisting of reinfection, reactivation, and latent infection. Narrowing down the infection profile of Toxoplasma is challenging in some cases. Therefore, careful diagnosis and extended follow-up of such patients are needed.
肾小管间质性肾炎和葡萄膜炎综合征是一种罕见的淋巴细胞相关性眼肾炎症性疾病，推测与药物使用和感染因子有关。刚地弓形虫是其中一种病原体，可在免疫功能低下或部分免疫功能正常的个体中引起脑炎、脑膜炎和葡萄膜炎。如果在筛查中刚地弓形虫免疫球蛋白 M 呈阳性，那么结果的解读并不简单，尤其是当免疫球蛋白 M 持续呈阳性时。
一名 34 岁亚裔男性出现发热、头痛和伴有触痛的淋巴结病，最初被诊断为脑膜炎。开始使用抗生素和双氯芬酸钠治疗发热。尽管经过一周的治疗，他的症状得到了缓解，但肾功能逐渐下降，随后进行了肾活检，结果显示为急性肉芽肿性间质性肾炎。一周后，双眼出现疼痛和视力模糊，出现双眼虹膜炎和角膜沉积物，因此诊断为急性肾小管间质性肾炎和双侧葡萄膜炎综合征。刚地弓形虫特异性免疫球蛋白 G 和免疫球蛋白 M 滴度均为阳性。尽管我们不能排除刚地弓形虫的近期感染，这可能最初导致了葡萄膜炎，但刚地弓形虫免疫球蛋白 G 亲和力试验表明这是一次远期感染，从而排除了脑膜炎和葡萄膜炎是近期刚地弓形虫感染引起的并发症的可能性。药物诱导的淋巴细胞刺激试验或双氯芬酸钠的淋巴细胞转化试验仅在测试的药物中呈阳性。仅使用眼部类固醇即可缓解葡萄膜炎，且无需全身使用类固醇即可使肾功能恢复正常。
我们遇到了一例双氯芬酸钠引起的肾小管间质性肾炎和葡萄膜炎综合征。在排除感染时，刚地弓形虫免疫球蛋白 M 持续阳性，而刚地弓形虫免疫球蛋白 G 亲和力试验表明存在“远期”感染。根据这两个结果，我们排除了近期感染。然而，应当注意的是，商业免疫球蛋白 G 亲和力所表示的“远期”感染仍然是再感染、再激活和潜伏感染的多重表现。在某些情况下，缩小刚地弓形虫的感染谱具有挑战性。因此，需要对这类患者进行仔细诊断和长期随访。
