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Focal segmental glomerulosclerosis lagged behind the onset of rheumatoid arthritis by 7 years A case report and literature review ∗

Yang Liu, MDa, Hong-yan Wen, PhD, MDa, , Li-hua Wang, MD, PhDb, Chen Wang, MD, PhDc Abstract Introduction: The co-existence of focal segmental glomerulosclerosis (FSGS) and rheumatoid arthritis (RA), presenting either

together or in succession, is very rare. A variety of histopathological features in the clinical renal disease may occur in RA. Only 8 studies have previously reported this poorly understood connection. Clinical findings/diagnoses: A case of a 54-year-old male with RA lasting for more than 7 years developed cheirarthritis as the first signs. Symmetric polyarthralgia and multiple swollen joints throughout the body were followed, accompanied with morning stiffness. Gradually, he suffered from albuminuria, hypoalbuminemia, edema, and hyperlipidemia in 2014. The patient had the history of administering loxoprofen, celecoxib, leflunomide, and methotrexate. He was diagnosed as RA, nephrotic syndrome. Renal biopsy confirmed FSGS. Conclusion: Our case and the review of the literature indicate that FSGS is one of the causes of nephrotic syndrome in RA. It strongly suggested that RA patients with the abnormal kidney functions should be routinely screened for FSGS to guide the therapy, achieve both RA and FSGS remission, determine a prognosis, and avoid end-stage renal lesion. Abbreviations: ANCA = antineutrophil cytoplasmic antibody, DMARD = disease-modifying anti-rheumatic drug, FSGS = focal

segmental glomerulosclerosis, NSAIDs = non-steroidal anti-inflammatory drugs, PIP = proximal interphalangeal, RA = rheumatoid arthritis.

Keywords: case report, focal segmental glomerulosclerosis, nephrotic syndrome, renal biopsy, rheumatoid arthritis

non-steroidal anti-inflammatory drugs (NSAID) and diseasemodifying anti-rheumatic drugs (DMARD).[2] FSGS is a cause of nephrotic syndrome and can lead to global sclerosis. In FSGS, the scarring occurs only in some of the glomeruli. Only part of glomeruli is damaged which can lead to kidney failure. FSGS has been reported in the patients with RA. However, FSGS and RA occur infrequently in the same patient and the association between them remains obscure.[3] The current study describes a confirmed case of RA in a patient diagnosed with FSGS on renal biopsy. A review of English literature has revealed and a correlation between RA and FSGS may be present, although pathogenic mechanisms are not fully elucidated.

1. Introduction A variety of histopathological features in the clinical renal disease may occur in rheumatoid arthritis (RA). Main histology patterns in RA are amyloidosis, papillary necrosis, chronic interstitial nephritis, vasculitis, and capillary proliferative glomerulonephritis.[1] In addition, a few rare types are also found in RA, including focal segmental glomerulosclerosis (FSGS). These renal changes have been considered to be mediated by an immunological and inflammatory procedures and/or by nephrotoxic effects of numerous drugs usually used in RA treatment, such as Editor: Worawit Louthrenoo. Funding: This work was supported by research grants from the National Natural Science Foundation of China (no. 81301532/H0603) and the Shanxi Science and Technology research projects of China (no. 201603D321074).

2. Case report A 54-year-old male presented to our department with arthritis, involving multiple joints. His symptoms started in 2007. When he first developed spontaneous arthritis of third proximal interphalangeal (PIP) joint, presented with painful swelling, accompanied by morning stiffness lasting for hours and relieved by warmth and activity. In July 2012, the above-mentioned symptoms were aggravated. Multiple arthralgia and swollen joints involved in bilateral PIP joints, wrists, elbows, knees, and ankles joints, along with a limited range of motion. He visited our hospital and was diagnosed as RA. The symptoms were relieved after starting on treatment with corticosteroids, NSAIDs (loxoprofen, celecoxib), and immunosuppressive agents (methotrexate, leflunomide). Having outpatient review and treatment regularly in our hospital, his condition was stable. At the beginning of 2015, he suffered from nontender subcutaneous nodules on the left forearm. The nodule could disappear with injection of corticosteroids. The

The authors have no conflicts of interest to disclose. a

Department of Rheumatology, Shanxi Medical University, the Second Hospital of Shanxi Medical University, N0.382 Wu Yi Road Taiyuan, Shanxi Province, b Department of Nephrology, c Department of Pathology, Shanxi Medical University, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi province, China. ∗

Correspondence: Hong-yan Wen, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China (e-mail: [email protected]).

Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution-No Derivatives License 4.0, which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. Medicine (2017) 96:1(e5789) Received: 7 August 2016 / Received in final form: 1 December 2016 / Accepted: 4 December 2016 http://dx.doi.org/10.1097/MD.0000000000005789

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Liu et al. Medicine (2017) 96:1

Medicine

test were negative, 24 hours urine protein 12.56 g/24 h, albumin 18.30 g/L (normal>40 g/L), serum total cholesterol 12 mmol/L (normal

Focal segmental glomerulosclerosis lagged behind the onset of rheumatoid arthritis by 7 years: A case report and literature review.

The co-existence of focal segmental glomerulosclerosis (FSGS) and rheumatoid arthritis (RA), presenting either together or in succession, is very rare...
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