Hong Kong Journal of Nephrology (2011) 13, 74e76

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CASE REPORT

Renal amyloidosis: A rare presenting manifestationof Hodgkin’s disease

Jai Prakash a,*, Sanjeev Kumar Behura a, Biplab Ghosh a,Shivendra Singh a, Usha b

aDepartment of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IndiabDepartment of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

Available online 2 October 2011

KEYWORDSAmyloidosis;Hodgkin’s disease;Minimal change disease;Nephrotic syndrome

* Corresponding author.E-mail address: jpojha555@hotma

1561-5413/$36 Copyright ª 2011, Hondoi:10.1016/j.hkjn.2011.09.001

Summary Renal amyloidosis leading to nephrotic syndrome is very rare in Hodgkin’s disease ascompared to minimal change disease. Amyloidosis usually develops insidiously after many yearsof active Hodgkin’s disease, and is often a late and irreversible complication. Concomitantpresentation of Hodgkin’s disease and nephrotic syndrome are rarely reported in the literature.We describe a 35-year-old female who presented simultaneously with Hodgkin’s disease andnephrotic syndrome, which was found to be secondary to renal amyloidosis on renal biopsy.

相比於腎臟的微小變化疾病，類澱粉沉積所致之腎病症候群在霍杰金氏病中非常罕見。在活性的

霍杰金氏病患者間，類澱粉沉積症通常潛伏多年，至後期演變成一個不可逆的併發症。至今，文

獻鮮有記載霍杰金氏病及腎病症候群的共同病發現象。以下是一位35歲的女性患者，同時呈現霍

杰金氏病及腎病症候群，後者經活組織檢驗證實是腎臟的類澱粉沉積症所致。

Introduction

Renal amyloidosis complicating Hodgkin’s disease (HD) isvery rare. We describe simultaneous occurrence of HD andnephrotic syndrome with kidney biopsy evidence of renalamyloidosis in a female patient.

Case report

A 35-year-old woman had low grade fever, cervical lymph-adenopathy for 1 year and gradually progressive anasarca

il.com (J. Prakash).

g Kong Society of Nephrology Ltd

of 2 months’ duration. Physical examination revealedanasarca, postural hypotension and non-tender, discreteleft lower cervical lymphadenopathy. Laboratory investi-gations showed proteinuria of 9.39 g/24 hours, hemoglobinof 10 g/dL, normal white blood cell and platelet counts andserum electrolytes, serum urea of 96 mg/dL, creatinine of3.0 mg/dL, cholesterol of 164 mg/dL, albumin of 2.4 g/dL,and globulin of 1.6 g/dL. Both kidneys were enlarged onultrasonography. Immunological assay was negative for HIV,hepatitis B and C. No monoclonal protein was detected onserum electrophoresis. Mantoux test was negative. Renalbiopsy showed focal irregular membranous thickening anddeposition of hyaline material in the mesangium and bloodvessels. Hyaline deposit in the mesangium and vessel wall

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Figure 1 Renal biopsy shows: (A) hyaline deposits in the glomerular basement membrane and mesangium (hematoxylin & eosin,400�); (B) orange red amyloid in the glomerular basement membrane and mesangium (Congo red, 400�).

Hodgkin’s disease presenting as renal amyloidosis 75

was positive for Congo red and crystal violet stains, con-firming the diagnosis of amyloidosis (Fig. 1). Lymph nodebiopsy revealed diffuse effacement of lymph nodes bya heterogeneous cellular infiltrate consisting of smalllymphocytes, eosinophils, plasma cells and macrophages.Classical Reed-Steinberg cells were seen on hematoxylinand eosin staining, confirming the diagnosis of HD. Amyloidmaterial was also demonstrated in lymph node tissue(Fig. 2). She was treated with chemotherapy using the ABVDregimen (doxorubicin, bleomycin, vinblastine, dacarbazine)along with dialysis. However, she died of sepsis and multi-organ failure.

Figure 2 Lymph node biopsy shows: (A) typical Reed-Steinbergamyloid which was positive for Congo red; (C) numerous eosinophi

Discussion

Renal amyloidosis as a presenting feature of HD is rarelyreported.1 Only 40 cases of HD with amyloidosis have beenreported in the literature from 1930 to 1986.2 Tuglular et aldid not find a single case of HD causing renal amyloidosisamong 287 cases of secondary amyloidosis.3 Similarly, nocase of renal amyloidosis due to HD was observed in a seriesof 230 cases from India.4 However, simultaneous occur-rence of HD and renal amyloidosis has been documented.1,5

Tuzuner et al documented that the period between diag-nosis of HD and development of renal amyloidosis were 1,

cells (hematoxylin & eosin, 400�); (B) nodular collection ofls (hematoxylin & eosin, 400�).

76 J. Prakash et al.

26 and 138 months in their three patients.6 Our patient hadHD for 1 year before development of nephrotic syndromedue to renal amyloidosis. Probably in our patient, the HDthat was undiagnosed for 1 year gave time for increasedsynthesis of interleukins and serum amyloid A, with subse-quent development of renal amyloidosis. In conclusion, weneed to be aware of renal amyloidosis, a rare complicationof HD presenting as nephrotic syndrome.

References

1. Thavaraj V, Dawar R, Arya LS. Renal amyloidosis in a child withHodgkin disease. Indian Pediatr 2002;39:677e80.

2. Dabbs DJ, Striker LM, Mignon F, Striker G. Glomerular lesions inlymphomas and leukemias. Am J Med 1986;80:63e70.

3. Tuglular S, Yalcinkaya F, Paydas S, Oner A, Utas C, Bozfakioglu S,et al. A retrospective analysis for aetiology and clinical findingsof 287 secondary amyloidosis cases in Turkey. Nephrol DialTransplant 2002;17:2003e5.

4. Chugh KS, Datta BN, Singhal PC, Jain SK, Sakhuja V, Dash SC.Pattern of renal amyloidosis in Indian patients. Postgrad Med J1981;57:31e5.

5. Das PK, Venugopal P, Bhasin S, Gopal R, Saikia T, Nair CN, et al.Nephrotic syndrome of amyloid etiology in Hodgkin’s disease.Indian J Cancer 1986;23:192e6.

6. Tuzuner N, Avano�glu Y, Aktuglu G, Do�gusoy G, Muftuoglu A.Amyloidosis in Hodgkin’s disease. Am J Med 1992;92:446e8.