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Open Access 01-12-2021 | Uveitis | Case report

Tubulointerstitial nephritis and uveitis syndrome following meningitis and systemic lymphadenopathy with persistent Toxoplasma immunoglobulin M: a case report

Authors: Yoshihiro Oya, Hidekazu Futami, Takuya Nakazawa, Kazuyuki Ishijima, Keiko Umemiya, Fumiyoshi Takizawa, Naoki Imai, Hiroshi Kitamura, Ryutaro Matsumura

Published in: Journal of Medical Case Reports | Issue 1/2021

Abstract

Background

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.

Case presentation

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.

Conclusions

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.

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Title: Tubulointerstitial nephritis and uveitis syndrome following meningitis and systemic lymphadenopathy with persistent Toxoplasma immunoglobulin M: a case report
Authors: Yoshihiro Oya
Hidekazu Futami
Takuya Nakazawa
Kazuyuki Ishijima
Keiko Umemiya
Fumiyoshi Takizawa
Naoki Imai
Hiroshi Kitamura
Ryutaro Matsumura
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Uveitis
Toxoplasmosis
Interstitial Nephritis
Meningitis
Lymphadenopathy
Published in: Journal of Medical Case Reports / Issue 1/2021
Electronic ISSN: 1752-1947
DOI: https://doi.org/10.1186/s13256-021-02909-z

At a glance: The STEP trials

Springer Medicine

Tubulointerstitial nephritis and uveitis syndrome following meningitis and systemic lymphadenopathy with persistent Toxoplasma immunoglobulin M: a case report

Abstract

Background

Case presentation

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Case presentation

Conclusions

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