Necrotizing glomerulonephritis associated with Hodgkin's disease.

Sir, The occurrence of various types of glomerulonephritis with haematological malignancies is well established w1±3x. Hodgkin's disease has been principally described in association with minimal-change nephropathy and rarely with membranous glomerulonephritis w1,2x. We report here a patient with Hodgkin's disease of the nodular sclerosing type, who initially presented with necrotizing glomerulonephritis, a very unusual association. Case. A 49-year-old woman discovered a tumour in the left inguinal region almost as large as a tennis ball that grew over a few days. A computerized axial tomography (CAT) of the abdomen demonstrated splenomegaly and multiple enlarged lymph nodes para-aortal, iliac, in the left inguinal region, and around the portal ®ssure. At this time the serum creatinine was 1.2 mgudl. On admission 3 days later, the serum creatinine was 3.2, BUN 36, uric acid 7.9 mgudl. No anti-neutrophil cytoplasmic antibodies (ANCA), anti-GBM anti-bodies, or anti-DNA antibodies were detected (results received later). Serum complement was normal. There was no evidence of cryoglobulinaemia, para-proteinaemia, infection with hepatitis B and C, or elevated anti-streptolysin O and anti-DNAse titre. IgG antibodies against Epstein±Barr virus (EBV) were detected. Proteinuria was present that was almost exclusively albumin (1100 mgu24 h) without detection of Bence Jones protein. The urine sediment revealed many acanthocytes and several red-cell casts. Ultrasound revealed enlarged kidneys with faded parenchyma. The clinical diagnosis of rapid progressive glomerulonephritis was established. Therapy with intravenous methylprednisolone (500 mgu day for 3 days) was started. A renal biopsy as well as surgical removal of the inguinal lymph node was performed the next day. Figure 1 shows the periodic acid±Schiff (PAS) staining of the renal biopsy. Intra-and extracapillary proliferation with segmental necrosis and crescent was present. Immuno-histological studies showed no granular or linear deposition of IgA or IgG. No dense deposits were observed on electron microscopy. A diagnosis of ongoing necrotizing glomerulo-nephritis without evidence of immune complexes or anti-GBM antibody deposition was made. The excised lymph node provided the diagnosis of Hodgkin's disease of the nodular sclerosis type. Since a bone-marrow biopsy as well as liver biopsy specimen revealed no evidence of in®ltration, a stage IIA was diagnosed (Ann Arbor classi®cation). The patient received one course of chemotherapy including cyclophosphamide, vincristine, and continuation of oral prednisone. Restaging 5 months later revealed only moderate residual lymph nodes, and the patient underwent radiation therapy for residual disease. At this time, the serum creatinine was 3.1 mgudl. There were no signs of glomerulonephritis activity in …