DR AMANDA VARGHESE1, A/PROF TRENT DAVIDSON2,5, A/PROF ARVIN DAMODARAN3,4, DR MANGALEE FERNANDO1,4
1Department of Nephrology, Prince Of Wales Hospital, Sydney , Australia, 2Department of Anatomical Pathology, Prince of Wales Hospital, Sydney , Australia , 3Department of Rheumatology, Prince of Wales Hospital, Sydney, Australia , 4School of Clinical Medicine, University of New South Wales, , , 5Western Sydney University, School of Medicine, , Australia
Biography:
Amanda Varghese is a nephrology advanced trainee through the East Coast Renal Network, NSW with an interest in chronic kidney disease, glomerulonephritis and kidney supportive care.
Background:
Drug induced sarcoidosis-like reaction (DISR) is a systemic granulomatous reaction like sarcoidosis and tuberculosis (TB) infection. While tumour necrosis factor alpha (TNF-α) inhibitors are used for sarcoidosis treatment, paradoxically, case reports implicate TNF-α inhibitors in DISR especially with pulmonary and cutaneous involvement. Data on renal involvement is limited. Herein we present a case of DISR presenting with an omental mass and renal failure from granulomatous interstitial nephritis (GIN) secondary to TNF-α inhibitor adalimumab.
Case Report:
A 40-year-old Indian woman employed in washing equestrian clothing was referred for creatinine rise from 70μmol/L to 185μmol/L over seven months. Urine sediment was bland with minimal albuminuria. Twelve months prior, adalimumab (40mg/fortnight) had been added to long-term methotrexate for deforming rheumatoid arthritis. Kidney biopsy showed granulomatous interstitial nephritis and eosinophils without necrosis. Abdominal CT showed a greater omental mass and prominent inguinal lymph nodes; and widespread metabolic activity on positron emission tomography indicated systemic disease. Biopsy of omentum and largest lymph node showed non-caseating granulomata. Pan mycobacterium polymerase chain reaction (PCR) and TB culture of tissue samples excluded mycobacterial infection. Similarly, pan fungal PCR and fungal cultures were negative. Serology excluded HIV, syphilis and zoonotic infections including brucellosis. Serum angiotensin-converting enzyme was normal. Tumour markers and tissue histology were negative for malignancy. Withdrawal of adalimumab stalled renal decline. Empiric steroid therapy reduced creatinine to 160μmol/L in two weeks. Tapering and discontinuation of steroids over months is planned.
Conclusion:
We describe an unusual presentation of DISR with an omental mass and GIN. Our case illustrates a temporal association between adalimumab initiation and GIN and the complexities in diagnosis due to mimicry such as TB, zoonotic infections and malignancy.