Purpose Sarcoidosis is a multisystem disease characterized by noncaseating granulomatous reaction frequently involving the lymph nodes, lungs, liver, skin and eyes. Acute renal failure (ARF) as an isolated manifestation of sarcoidosis is rare. We describe a case of sarcoidosis presenting as transient polyarthritis and ARF due to isolated granulomatous infiltration.
Case Report 57 year old white male was admitted with one week history of additive polyarthritis and ARF in August 2004. Twenty two years prior to admission he had an intestinal bypass surgery for morbid obesity. Fifteen years prior to admission he had symptomatic cholelithiasis requiring cholecystectomy and recurrent calcium oxalate nephrolithiasis requiring lithotripsy. Physical examination was notable for synovitis in elbows, metacarpophalangeal joints and bilateral knee effusions. Synovial fluid analysis revealed white blood cells 3,675/mm3. Serum creatinine was 3.5 mg/dL elevated from a baseline of 1.0 g/dL in April 2003. Other laboratory findings included serum calcium 9.0 mg/dL; 24-hour urine protein and calcium were 1.4 gram and 81 mg respectively; non-anion gap metabolic acidosis; liver function tests, serum complements, serum and urine electrophoresis and 1,25-dihydroxyvitamin D were normal; hepatitis B surface antigen, hepatitis C, antinuclear and antineutrophil cytoplasmic antibodies were absent. Angiotensin-converting enzyme level was 88 U/L (normal, 8-52 U/L). Chest x-ray and renal ultrasound were normal. His arthritic symptoms resolved spontaneously within a few days. Renal biopsy showed granulomatous interstitial nephritis with noncaseating granulomas consistent with sarcoidosis. Bacterial, fungal and mycobacterial infections were excluded. Prednisone 60 mg daily resulted in significant improvement in renal function in one month.
Discussion and Conclusion Clinically apparent primary renal involvement is rare in sarcoidosis. Renal dysfunction is most often due to hypercalcemia, hypercalciuria, nephrolithiasis, nephrocalcinosis, glomerulonephritis or interstitial nephritis without sarcoid granulomata. Renal granulomas seen in up to 40% cases of multisystem disease (in autoptic or bioptic circumstances) seldom cause renal impairment. We report a rare case of sarcoidosis presenting as transient polyarthritis and ARF due to isolated granulomatous renal parenchymal infiltration. While uncommon, renal sarcoidosis should be considered in the differential diagnosis of ARF of uncertain origin. Full recovery of renal function may be expected with early diagnosis and prolonged treatment with steroids which may prevent interstitial fibrosis.
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