A case of Graves’ disease associated with membranoproliferative glomerulonephritis and leukocytoclastic vasculitis

Abstract

Background The association of hyperthyroidism with renal disease is very rare and the importance of timely clinical recognition cannot be overemphasized. Case presentation An 11-year-old girl presented with gastrointestinal symptoms while hypertension, edema and abdominal pain were noticed on clinical examination. Laboratory investigation revealed: hemoglobin 9.4 (11.5-15.5) g/dL, total white cell count 16 (4.5-12)×109/L, platelets 247 (150-450)×109/L, C-reactive protein (CRP) 31.8 (<5) mg/L, blood urea nitrogen (BUN) 126 (13-43) mg/dL, creatinine 0.98 (0.53-0.79) mg/dL, albumin 25 (35-52) g/dL, complement factor C3 0.7 (0.9-1.8) g/L, complement factor C4 0.1 (0.1-0.4) g/L, tri-iodothyronine 6.5 (2.5-5.2) pg/mL, free thyroxine 2.4 (1-1.7) ng/dL, thyroid stimulating hormone (TSH) <0.02 (0.5-4.3) mU/L. Urinalysis showed nephrotic range proteinuria. Renal function deteriorated necessitating hemodialysis (HD). A renal biopsy revealed an immune complex-mediated membranoproliferative glomerulonephritis (MPGN). Elevated thyroid hormones and suppressed TSH levels with elevated thyroperoxidase antibodies and thyroid stimulating immunoglobulins confirmed the diagnosis of Graves' disease. Corticosteroids were commenced and eventually thiamazole was added with gradual improvement of renal function, cessation of HD and discharge from the hospital. Conclusions Graves' disease complicated by MPGN is extremely rare, but can cause life-threatening complications.

Minimal change disease associated with Graves’ disease and methimazole use

“…Among these case reports, there is one of a patient who experienced a nephropathy associated with chronic use of low-dose methimazole, [6] a case of MCD that preceded the clinical manifestations of Graves' disease for several years [11], a case of MCD in a patient who was being treated with propylthiouracil [12], and, one case in which the simultaneous onset of MCD and Graves' disease was reported [10]. Other types of kidney injury associated with Graves' disease described in the literature include membranoproliferative glomerulonephritis [14], as reported in a case where it was mediated by immune complexes [15].…”

A Case of Unilateral Exophthalmos Due To Thyroid Orbitopathy in A Clinically Euthyroid Patient

“…(12). Keenswijk et al reported another case of GD with membranoproliferative glomerulonephritis (MPGN) in an 11 years old girl (13). MPGN has been reported in other autoimmune thyroid disorders as well.…”

A Case of New-Onset Nephrotic Syndrome

“…4 A patient with Graves disease with anti-thyroperoxidase antibodies and TSI, nephrotic syndrome, and MPGN with IgG-positive deposits 5 and an 11-year-old girl with hyperthyroidism (TSI positive), nephrotic syndrome, and MPGN have also been described. 6 In each of these cases, other secondary causes were excluded. Therefore, the combination of MPGN and Graves disease suggests an association between autoimmune thyroid disease and renal involvement, although the rarity of clinical observations make any conclusions speculative.…”