ESP Nephropathology WG Slide Seminar Krakow 2010 DRUGS

ESP Nephropathology WG Slide Seminar (Krakow 2010) “DRUGS AND KIDNEY” Case No. 6 Dušan Ferluga Institute of Pathology, Faculty of Medicine University of Ljubljana, Slovenia

Medical history (I) of a 46 -year-old woman 1974 (age 13) - Juvenile rheumatoid arthritis 1974 -83 - Th: corticosteroids, gold, NSAID 1983 (age 22) - Overlapping SLE (5 ARA: butterfly rash, arthritis, ANA pos, a-ds. DNA pos 0. 98, proteinuria 1. 1 g/d) 1 st renal biopsy Class I, ID mes ++, sed +, sep+-/+ 1983 -89 - Th: Cyclophosphamide pulses, corticosteroids Remission of most symptoms, release of laboratory findings Recurrent deep vein thrombosis assoc. Ig. G a. CL in high titer Dg. APS Th warfarin

1 st kidney biopsy in 1983 (age 22) Medulla and cortex with 9 glomeruli ISN/RPS Class I (min mes lupus nephritis) IA 0, IC 0 IF: » full-house « glom mes ID EM: dense deposits mesangial/paramesangial ++, sparse, segmental sed+, sep+-/+, endothelial TRI myxovirus-like +, no myelin-like cytoplasmic inclusions

1 st kidney biopsy

1 st kidney biopsy – EM

Medical history (II) of a 46 -year-old woman 1989 (age 30) - ANA pos, a-ds. DNA low pos 0, 45 2000 (age 41) - Positive skin biopsy band test by DIF Urinalysis: norm 2001 (age 42) - ANA pos 1: 640, ENA pos HTE 1, a-ds. DNA pos 0. 86, Ig. G a. CL pos (>30) Th: cyclosporin (RR ) replaced methothrexate (side effects) replaced 2001 -2006 - Th: chloroquine 250 mg/d (cumul. 413 g)

Clinical / laboratory findings at 2 nd biopsy 2006 (age 46) - Lab parameters of inflamm (SR, CRP) low Reduced joint swelling and pain, ARA criteria not fulfilled (SLE in remission? ) S-creatinine 150 µmol/L ( ) Urinalysis: proteinuria 0. 25 -0. 5 g/d, mild erytrocyturia and leukocyturia 2 nd renal biopsy

2 nd kidney biopsy in 2006 (age 46) Medulla and cortex with 14 glomeruli Ø LM: Widespread global (8/14) and segmental (1/14) glomerulosclerosis Focal (25%) interstitial fibrosis and tubular atrophy Moderate arteriosclerosis and arteriolosclerosis Ø IF: Glom mesangial Ig. G, Ig. M and C 3 in traces ( ) Ø EM: Traces of dissolved mesangial and subepithelial deposits. No features of active lupus nephritis. A variety of cytoplasmic inclusions in renal cells Ø Dg. : 1. Class I lupus nephritis resolved (Class IVG (C)? ) 2. FSGS, coincidental drug-induced?

2 nd kidney biopsy

2 nd kidney biopsy – EM

2 nd kidney biopsy – EM

2 nd kidney biopsy – EM

2 nd kidney biopsy in 2006 (age 46) CONCLUSION Ø EM: Numerous myelin- and zebra-like lamellar cytoplasmic inclusions, irregularly distributed in variety of renal cells are ultrastructural features compatible with those of Fabry disease, particularly in heterozygous woman. However, additional findings of peculiar curvilinear bodies, convincibly demonstrated in vascular smooth muscle cells and one of the glomerular mesangial cells are highly suggestive of iatrogenic chloroquine-induced renal phospholipidosis.

Skin biopsy – EM

First skeletal muscle biopsy – EM

Second skeletal muscle biopsy – EM (6 months after chloroquine withdrawal)

Skin and skeletal muscle biopsies (age 46) Ø EM: Myelin-like and occasionally zebra-like lamellar cytoplasmic inclusions were demonstrated in the sarcoplasm of myofibers and in a variety of cells in the skin biopsy. Associated curvilinear cytoplasmic bodies, present in abundance in the sarcoplasm of myofibers and to lesser extent in the vascular smooth muscle cells. Complete clearance of lamellar inclusions but remnants of curvilinear bodies in follow-up skeletal muscle biopsy six months after chloroquine withdrawal.

Final diagnosis: IATROGENIC CHLOROQUINE-INDUCED SYSTEMIC PHOSPHOLIPIDOSIS mimicking Fabry disease

Arguments confirming final diagnosis: Ø Curvilinear cytoplasmic inclusions in addition to myeloid and zebra bodies Ø Slowly progressive renal insufficiency and biopsy proven nephrosclerosis could much easier be ascribed to chloroquine in cumulative dose of 413 g than to SLE being in remission Ø Considerable improvement of renal function and clearance of lamellar bodies from skeletal muscle after 6 months of discontinuation of chloroquine therapy Ø Absence of ultrastructural features of Fabry disease in the first renal biopsy Ø Lack of family history of Fabry disease Ø Peripheral leukocyte testing for -galactosidase A level within normal range and genetic analysis excluding mutation of -galactosidase A gene

Chloroquine side-effects in humans retinopathy (1959), neuromyopathy (1963), cardiomyopathy (1977), nephropathy (2003) – iatrogenic phospholipidosis shared with more than 50 drugs with different therapeutic actions but all cationic, amphiphilic and lysosomotropic

Literature on chloroquine-induced phospholipidosis Case reports Underlyin g Disease Chloroquine Time Cumm Müller. Hocher J et al, 2003 Sjögren syndrome 11 mo Albay D et al, 2005 Bracamonte ER et al, 2006 Wojwodt A et al, 2007 Lamellar bodies Curvilin bodies Prot (g/d) S-Creat (mg/d. L) 51 g +++/+ + cell type? 0 1. 0 -2. 1 Rheum arthritis 18 mo 130 g +++/+ 0 (muscle biopsy+ ) traces 2. 2 Undefined autoimm disease 10 yrs intermitent +++/+ 0 1. 2 1. 3 SLE Several years? +++/+ 0 2 CCr 64 ml/min

Tentative mechanisms involved in pathogenesis of chloroquine-induced phospholipidosis • Adsorption to plasma membrane and accumulation in lysosomes • Formation of amphiphilic cationic drug–polar lipid complexes resistant to digestion • Inhibition of lysosomal enzyme activities through drug-induced increase of p. H • Direct drug induced strong but reversible inhibition of lysosomal phospholipases A and C and possibly other hydrolases

Patients (Kidney biopsy files 1987 -2007) 25 pts, mostly SLE, on chloroquine 250 mg/d (1 day – 8 yrs) ______________________ Chloroquine treatment Renal lipidosis No. of pts Duration Cummulative Withdrawn before biopsy Yes 6 (24%) 11 days – 4. 5 yrs 5. 3 – 413 g 0 Suspected 3 (12%) 37 days – 10 mo 11. 7 – 79 g 0 No 2 (8%) 1 day – 2 days 0. 5 – 1. 0 g 0 No 14 (56%) 27 days – 5 yrs 9. 3 – 460 g 3 mo – 8 yrs