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Tubulointerstitial Nephritis-Uveitis Syndrome

Tubulointerstitial Nephritis and Uveitis Syndrome


Presentation

  • Results: A 19-year-old woman presented with decreased visual acuity and acute renal failure after starting lamotrigine.[ingentaconnect.com]
  • Documentation: The TubuloInterstitial Nephritis and Uveitis syndrome (TINU) can be diagnosed when specific criteria are present.[meducator3.net]
  • In the present case, the patient also presented with nonspecific systemic manifestations such as fever, fatigue, and weight loss, which was consistent with previous literature.[journals.lww.com]
  • Mild renal insufficiency was present. There is no single diagnostic test available for TINU syndrome.[joii-journal.springeropen.com]
Weight Loss
  • Hyperthyroidism may represent an unrecognized feature of the disorder and potentially contributes to the accompanying weight loss.[pediatrics.aappublications.org]
  • We present a case of a 55 year old female with a 3-month history of asthenia and weight loss. Blood tests showed anemia and renal insufficiency. Renal biopsy revealed interstitial nephritis and the bone marrow biopsy showed caseating granuloma.[actamedicaportuguesa.com]
  • Abstract For 10 weeks a 25-year-old man had been suffering from tiredness, fatigue, nausea and a 16 kg weight loss. Erythrocyte sedimentation rate (83/133 mm), serum C-reactive protein (5.5 mg/dl) and creatinine (5.05 mg/dl) were all elevated.[ncbi.nlm.nih.gov]
Fatigue
  • Patients with TINU syndrome present with nonspecific systemic manifestations including 2 fever, fatigue, headache, malaise, weight loss, myalgia, and arthralgia.[journals.lww.com]
  • With reno-ocular manifestations, TINU syndrome is accompanied by symptoms such as fever, fatigue, malaise, anorexia, vomiting, and arthralgia. TINU syndrome is reported mainly in children or adolescent girls, and it is rare in adults.[ekjm.org]
  • Abstract For 10 weeks a 25-year-old man had been suffering from tiredness, fatigue, nausea and a 16 kg weight loss. Erythrocyte sedimentation rate (83/133 mm), serum C-reactive protein (5.5 mg/dl) and creatinine (5.05 mg/dl) were all elevated.[ncbi.nlm.nih.gov]
  • […] increased beta-2-microglobulin, low grade proteinuria, urinary eosinophils, pyruria or hematuria without infection, urinary white cell casts, normoglycemic glucosuria (3) a systemic illness lasting 2 weeks, with a combination of fever, weight loss, malaise, fatigue[meducator3.net]
Anemia
  • Blood tests showed anemia and renal insufficiency. Renal biopsy revealed interstitial nephritis and the bone marrow biopsy showed caseating granuloma. One month later anterior uveitis of the left eye appeared.[actamedicaportuguesa.com]
  • , pyruria or hematuria without infection, urinary white cell casts, normoglycemic glucosuria (3) a systemic illness lasting 2 weeks, with a combination of fever, weight loss, malaise, fatigue, rash, abdominal pain, flank pain, arthralgias, myalgias, anemia[meducator3.net]
  • Laboratory examination revealed mild normocytic anemia with 11.9% eosinophilia, serum creatinine 282.8 mmol / L (reference 35.4-97.2), a positive IgG antibodies Epstein Barr virus.[oatext.com]
  • In 65% of patients, ocular symptoms follow acute interstitial nephritis by a median time of 1 month, but can occur up to 14 months later.4 They generally suffer from weight loss and anemia, and have a raised ESR.[japi.org]
Abdominal Pain
  • pain, flank pain, arthralgias, myalgias, anemia, abnormal liver function tests, eosinophilia, elevated ESR ( 40 mm in first hour) Low grade proteinuria is indicated by one of the following: (1) 1 or 2 urinary protein on semi-quantitative test (2) spot[meducator3.net]
  • The main clinical manifestations are fever, weight loss, abdominal pain, arthralgias, myalgias and may be associated with uveitis.[oatext.com]
  • It may be accompanied by nonspecific systemic symptoms such as fever, involuntary weight loss, fatigue, loss of appetite, abdominal pain, and joint pains. [1] Diagnosis [ edit ] This section is empty.[en.wikipedia.org]
  • A 61-year-old woman was admitted to this hospital because of a 2-month history of abdominal pain and weight loss and an elevated serum creatinine level. On admission, physical examination was normal except for mild abdominal tenderness.[nejm.org]
  • The most common initial symptoms of the TINU syndrome are fever, anorexia, weight loss, fatigue, arthralgias, myalgias, and abdominal pain. 11 Our patient had typical laboratory findings indicating tubular renal damage, such as increased urinary beta-[healio.com]
Vomiting
  • With reno-ocular manifestations, TINU syndrome is accompanied by symptoms such as fever, fatigue, malaise, anorexia, vomiting, and arthralgia. TINU syndrome is reported mainly in children or adolescent girls, and it is rare in adults.[ekjm.org]
  • She denied joint pains, nausea/vomiting, diarrhea, or other new skin lesions. She was up to date with all of her vaccinations.[webeye.ophth.uiowa.edu]
  • It is characterized by abdominal pain; fever; nausea; vomiting; and occasionally diarrhea.[icd10data.com]
  • Clinical History AIN usually presents with non-specific symptoms, such as: Nausea and vomiting ; Generalised weakness; Lethargy. However, it must be remembered that AIN can be symptomless.[myvmc.com]
  • […] month Autoimmune Sjögren’s Syndrome Sarcoidosis SLE Hypocomplementemic tubulointerstitial nephritis IgG4 nephritis associated with: autoimmune pancreatitis or Miculicz Syndrome Symptoms and clinical findings Nonspecific extra-renal symptoms: nausea, vomiting[renalandurologynews.com]
Nausea
  • Abstract For 10 weeks a 25-year-old man had been suffering from tiredness, fatigue, nausea and a 16 kg weight loss. Erythrocyte sedimentation rate (83/133 mm), serum C-reactive protein (5.5 mg/dl) and creatinine (5.05 mg/dl) were all elevated.[ncbi.nlm.nih.gov]
  • However, 3 months before admission, she had presented to her general practitioner complaining of anorexia, nausea, lethargy, fevers and aches.[mja.com.au]
  • She denied joint pains, nausea/vomiting, diarrhea, or other new skin lesions. She was up to date with all of her vaccinations.[webeye.ophth.uiowa.edu]
  • It is characterized by abdominal pain; fever; nausea; vomiting; and occasionally diarrhea.[icd10data.com]
  • Clinical History AIN usually presents with non-specific symptoms, such as: Nausea and vomiting ; Generalised weakness; Lethargy. However, it must be remembered that AIN can be symptomless.[myvmc.com]
Abdominal Bruit
  • He had no abdominal bruit. His hemoglobin was 12 gm/dl, TLC 6800/cumm and ESR 20 mm/1 st hour. His blood urea was 64 mg/dl and serum creatinine was stable at 3 mg/dl during the hospital stay.[ncbi.nlm.nih.gov]
Hypertension
  • Rennke HG, Brenner BM: Therapeutic advantage of converting enzyme inhibitors in arresting progressive renal disease associated with systemic hypertension in the rat. J Clin Invest 77: 1993-2000. ‎[books.google.com]
  • She had also proteinuria; hematuria; aciduria; kidney failure and grade I hypertensive retinopathy.[omicsonline.org]
  • Case Report A 16-year-old male presented with hypertension, prolonged fever and impaired renal function. Three months prior to presentation he developed headache and was detected to have high blood pressure.[ncbi.nlm.nih.gov]
  • She had hypertension, raised levels of inflammatory markers (C-reactive protein: 2.6 mg/dL; erythrocyte sedimentation rate: 96 mm/first hour), a glomerular filtration rate (GFR) of 48 ml/min/1,73m 2 , hypokalemia, metabolic acidosis, leukocyturia, glucosuria[bjn.org.br]
  • Radiation This may occur 6-12 months after radiotherapy, with hypertension, anaemia and oedema. 50% progress to chronic kidney disease. Alternatively, it may develop over several years - presenting with hypertension and proteinuria sometimes.[patient.info]
Musculoskeletal Pain
  • Her symptoms of musculoskeletal pain and cough were much less than before. A Schirmer test 6 mm (during five minutes) and a rose bengal test were negative.[ard.bmj.com]
Eye Pain
  • The first case in the series was that of a 15-year-old boy with left eye pain and iridocyclitis, reduced visual acuity, and flu-like symptoms.[mdmag.com]
  • Case 2 A 14-year-old girl visited a neighborhood clinic for right eye pain, and bilateral iridocyclitis was detected. She did not exhibit symptoms such as headaches or ringing in the ears.[link.springer.com]
  • In 65% of patients, ocular symptoms follow acute interstitial nephritis by a median time of 1 month, but can occur up to 14 months later. 2 The most common systemic features are fever, weight loss, fatigue and malaise (50%); and eye pain and redness are[mja.com.au]
  • History Patients will usually present with typical anterior uveitis symptoms (eye pain, redness, decreased vision and photophobia). Symptoms of TIN are vague and include fever, malaise, fatigue and flank pain.[eyewiki.aao.org]
Hypertensive Retinopathy
  • She had also proteinuria; hematuria; aciduria; kidney failure and grade I hypertensive retinopathy.[omicsonline.org]
Burning Sensation
  • (Figs. 1 and 2 ) Six months after being admitted, and while tapering prednisolone to 15mg per day, he started presenting burning sensation, photophobia and redness in both eyes, accompanied by decreased visual acuity.[scielo.mec.pt]
Kidney Failure
  • She had also proteinuria; hematuria; aciduria; kidney failure and grade I hypertensive retinopathy.[omicsonline.org]
  • It causes the kidneys to work less well and can cause severe kidney failure. Like most diseases affecting the kidney, it produces very few symptoms unless the kidneys are quite severely affected.[edren.org]
  • J Bras Nefrol 38(1):132. doi:10.5935/0101-2800.20160019 Received: Junho 16 2015; Accepted: Setembro 28 2015 INTRODUCTION Tubulointerstitial nephritis (TIN) is a significant cause of kidney failure in children and adults, and it is characterized by renal[bjn.org.br]

Workup

  • A uveitis workup was recommended by her ophthalmologist. The differential diagnoses included post-infectious uveitis, sarcoidosis, Behçet’s, TINU syndrome, Lyme disease and HLA-B27-associated uveitis.[the-rheumatologist.org]
  • To complete the diagnostic workup of tubulointerstitial nephritis, an ophthalmic examination was performed and we identified fine keratic precipitations which was consistent with previous anterior bilateral uveitis.[journals.lww.com]
  • Further workup reveals urine protein 150 mg/dL, urine albumin 11 mg/dL, urine creatinine 144 mg/dL. Fractional excretion of beta-2 microgloblulin is high. Her renal ultrasound and chest radiographare unremarkable.[ajkdblog.org]
  • General Investigation The patient usually needs a complete workup.[myvmc.com]
Anergy
  • […] lymphocytes; decreased CD4/CD8 ratio; an increased expression of CD25; the low-affinity receptor for interleukin-2 on T lymphocytes; higher circulating levels of soluble tumor necrosis factor receptor during the active stage of the disease; clinical anergy[omicsonline.org]
Abnormal Renal Function
  • renal function (elevated serum creatinine, decreased creatinine clearance) (2) abnormal urinalysis with increased beta-2-microglobulin, low grade proteinuria, urinary eosinophils, pyruria or hematuria without infection, urinary white cell casts, normoglycemic[meducator3.net]
  • In view of her abnormal renal function she was referred to the renal team for further assessment.[nature.com]
  • Mandeville and colleagues [ 4 ] wrote helpfully on this topic and suggested that the clinical diagnosis of tubulointerstitial nephritis could be made if three criteria were fulfilled: (1) abnormal renal function; (2) abnormal urinalysis with the presence[academic.oup.com]
  • The clinical diagnostic criteria for AIN in probable TINU syndrome are a combination of the presence of all 3 factors: (1) abnormal renal function (elevated serum creatinine or a decreased clearance), (2) abnormal urinalysis results (elevated urinary[jamanetwork.com]
Creatinine Decreased
  • , decreased creatinine clearance) (2) abnormal urinalysis with increased beta-2-microglobulin, low grade proteinuria, urinary eosinophils, pyruria or hematuria without infection, urinary white cell casts, normoglycemic glucosuria (3) a systemic illness[meducator3.net]
CD8 Lymphocytes Decreased
  • This is supported by reports of a decreased peripheral CD3 , CD4 and CD8 lymphocytes; decreased CD4/CD8 ratio; an increased expression of CD25; the low-affinity receptor for interleukin-2 on T lymphocytes; higher circulating levels of soluble tumor necrosis[omicsonline.org]
Chlamydia Trachomatis
  • Prior infections with Epstein-Barr virus, herpes zoster virus and Chlamydia trachomatis have been linked in some cases [ 4 , 7 , 8 ].[academic.oup.com]
Human Papillomavirus
  • To the Editors: We report two cases diagnosed as having tubulointerstitial nephritis and uveitis (TINU) syndrome and a possible association with human papillomavirus (HPV) vaccine.[healio.com]
HLA-DR1
  • HLA-B14 was also found to be associated with TINU syndrome in our patients, but this gene is in linkage disequilibrium with HLA-DR1, and most likely is not independently associated with TINU syndrome.[iovs.arvojournals.org]
  • A strong association with HLA-DR1, particularly in a North American and German patients has been reported. There were also HLA-DQ associations in some case reports.[omicsonline.org]
HLA-DQ1
  • , as determined by serologic techniques, and HLA-DQ1 or HLA-DQ5 was found in seven of nine individuals with TINU syndrome for whom HLA-DQ testing was reported. 5 6 10 11 Furthermore, HLA-DQ5 is strongly linked to HLA-DR1 and DR10 and weakly to DR12, DR14[iovs.arvojournals.org]

Treatment

  • Treatment includes corticosteroids and, eventually, other immunosuppressant agents. Renal disease is usually benign and resolves spontaneously or after treatment with systemic corticosteroids. Uveitis, however, may be chronic or recurrent.[bjn.org.br]
  • DESIGN: Prospective, observational, multicenter, partly placebo-controlled treatment trial. PARTICIPANTS: Nineteen children with a biopsy-proven TIN. METHODS: Patients were treated with prednisone or followed without treatment.[f1000.com]
  • Her kidney function normalized, and uveitis resolved shortly after induction of treatment. No recurrence of either nephritis or uveitis was observed during tapering or after discontinuation of treatment.[joii-journal.springeropen.com]
  • Beginning with the basic principles of the disease, its diagnosis and management, the following sections discuss the treatment of numerous different infectious, non infectious, masquerade and autoimmune syndromes.[books.google.com]
  • In this review we want to show advances in diagnostics and treatment as well as progress in deciphering the pathogenesis.[ncbi.nlm.nih.gov]

Prognosis

  • Prognosis Generally good as the condition responds well to corticosteroids. American Academy of Ophthalmology.[eyewiki.org]
  • The ophthalmic and renal prognosis of this syndrome seems favorable with corticosteroid treatment. The oculorenal syndrome or TINU syndrome is probably of immunological origin.[sjkdt.org]
  • Had he presented at a later stage, however, the complications of anterior uveitis could have adversely affected his prognosis.[healio.com]
  • Mackensen F, Smith JR, Rosenbaum JT (2007) Enhanced recognition, treatment, and prognosis of tubulointerstitial nephritis and uveitis syndrome. Ophthalmology 114(5):995–999 CrossRef PubMed Google Scholar 17.[link.springer.com]
  • Prognosis is favorable with full recovery in 80% of cases and depends on the degree of tubulointerstitial fibrosis. Patients with progressive renal failure are treated with prednisone 1 mg / kg for three to six months and then slowly tapered.[oatext.com]

Etiology

  • Etiology It is thought to be an immune-mediated process that can be drug-related, infection-related, or idiopathic and can account for 10-15% of patients with acute renal failure.[eyewiki.org]
  • Sarcoidosis that is one of the etiologic factors was not found. Renal sonography and voiding cystography were unremarkable. A renal biopsy was performed.[journals.lww.com]
  • The etiology of this tubulointerstitial nephritis and uveitis syndrome was not clear. Immunological evaluation showed a slight decrease of the OKT4/OKT8 ratio in the peripheral blood.[karger.com]
  • Birnbaum AD, Jiang Y, Vasaiwala R, Tessler HH, Goldstein DA (2012) Bilateral simultaneous-onset nongranulomatous acute anterior uveitis: clinical presentation and etiology. Arch Ophthalmol 130(11):1389–1394 CrossRef PubMed Google Scholar 5.[link.springer.com]

Epidemiology

  • The 2009 prospective multi-center epidemiologic survey of uveitis in Japan. Jpn J Ophthalmol. 2012;56(5):432–5. View Article PubMed Google Scholar Jones NP. The Manchester uveitis clinic: the first 3000 patients- epidemiology and casemix.[ojrd.biomedcentral.com]
  • The incidence of TINU syndrome may be increasing and the epidemiology is possibly changing with a higher proportion of men and older persons affected. 2.[academic.oup.com]
  • Epidemiology The true prevalence of this syndrome is unknown, likely secondary to poor recognition of the disease [2].[webeye.ophth.uiowa.edu]
  • Epidemiology Relative Frequencies of Etiologies Drugs : account for 70-75% of acute interstitial nephritis cases Antibiotics : account for 30-49% of drug-associated acute interstitial nephritis cases Infections : account for 4-10% of acute interstitial[mdnxs.com]
Sex distribution
Age distribution

Pathophysiology

  • We would appreciate the comment of the authors on the two following issues: (1) Although they elegantly suggested the essential role of ANS in the pathophysiology of TTS, no details have been ... heart is not only made by muscle and vessels, but it is[paperity.org]
  • Pathology/Etiology The precise pathophysiology is unknown, but one hypothesis describes auto-antibody formation against uveal and tubular cells from hapten-induced cytokine production to certain antibiotics and non-steroidal anti-inflammatory drugs [4[webeye.ophth.uiowa.edu]
  • Tubulointerstitial diseases of the kidney encompass diverse etiologies and pathophysiologic processes, and the patient can present with acute or chronic conditions.[emedicine.medscape.com]
  • It mostly occurs in adolescents and young females, with a median age of onset of 15 years. 2 Much of the underlying pathophysiology remains unclear; however, T lymphocytes have been reported to play a significant role in this syndrome. 3 Certain associations[the-rheumatologist.org]
  • The mean age of presentation is 15 years (range: 9 to 74 years). 2,3 The pathophysiology of the syndrome is uncertain but prior infection or the use of medications such as antibiotics or non-steroidal anti-inflammatory drugs have been linked to TINU syndrome[healio.com]

Prevention

  • Early detection and steroid treatment may prevent renal complications.[mja.com.au]
  • A Step Forward I begin this commentary with a general appreciation for the report of the Genocide Prevention Task Force (the Albright-Cohen Report).1 The contents of the report are a decisive step forward in the ...[paperity.org]
  • How to use an article about therapy or prevention. B. What were the results and will they help me in caring for my patients? Evidence-Based Medicine Working Group. JAMA 1994;271:59-63. 79.[books.google.com]
  • Supported in part by the MacDonald Family Foundation, Los Angeles, CA (RDL), Research to Prevent Blindness, Inc. (JRS, TMM, JTR, GNH), and the David May II Endowed Professorship (GNH). GNH is a recipient of a Research to Prevent Blindness, Lew R.[iovs.arvojournals.org]

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