Malakoplakia is an uncommon inflammatory process usually associated with chronic urinary tract infections. The urinary bladder and ureters are commonly affected, although other sites including lymph nodes, bone, lung, gastrointestinal tract, skin, prostate, aqd adrenals may be involved (I). Renal parenchymal involvement can be associated with renal failure (2). This report describes the clinical course of renal parenchymal malakoplakia associated with renal failure in a patient with systemic lupus erythematosus.Case report. A 16-year-old white woman presented with thrombocytopenic purpura, arthralgias, and Raynaud's phenomenon. Physical examination revealed splenomegaly and petechiae. Laboratory test values included a platelet count of 37,GOO/mm3, hematocrit of 24% with elevated erythrocyte-bound IgG, white blood cell count of 2,700/mm3, and a titer of 1 : 640 for antibodies to nuclear antigens. Systemic lupus erythematosus (SLE) was diagnosed. The thrombocytopenia improved after administration of prednisone (80 mg/day), and resolved after splenectomy. Prednisone was discontinued.
AM07108-07.Four years later, a routine urinalysis revealed I + proteinuria, 10 red blood cellslhigh-power field, and 40-50 white blood celldhigh-power field. Casts were not seen and urine culture grew lo3 colonieslml of gram-positive cocci. Nine months later, a urinalysis showed 4+ proteinuria, mild hematuria and granular casts, and serum creatinine value was 4.0 mg/dl. The patient complained of urinary frequency without dysuria, and the serum creatinine level climbed to 9 mg/dl over the subsequent 3 weeks. The patient had not used analgesics excessively. A computerized tomography scan of the:'urinary collecting system showed normal results and the kidney size was normal. Percutaneous renal biopsy revealed prominent interstitial fibrosis with minimal glomerular abnormalities, but the specimen was inadequate for further studies. Prednisone (60 mg/day) was begun, but 1 month later the serum creatinine level rose to 11.6 mg/dJ, and a urine culture grew colonies of Escherichia coli > lO'/ml. Cephalexin was begun and the patient was referred to the University of Washington Hospital.Upon admission, she denied recent symptoms of active SLE and physical examination was noncontributory. Urinalysis revealed 2+ proteinuria, 1 + glycosuria, 1 + white blood cells, no red blood cells, and no cellular casts. Creatinine clearance was 4 m h i n u t e and several urine cultures grew 103->105 E colilml. The patient was started on hemodialysis. A repeat percutaneous renal biopsy was unsuccessful and an open, right renal biopsy was performed.At surgery, the kidney was edematous and pale, and the capsule appeared thickened. A small wedge biopsy was obtained. Of 109 glomeruli examined by light microscopy, 2 contained synechiae and 1 was obsolescent. The glomeruli had a few focal subepithe-
