Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Nodular Glomerulosclerosis in a Nondiabetic S. K. Samantaray To cite this article: S. K. Samantaray (1975) Nodular Glomerulosclerosis in a Nondiabetic, Postgraduate Medicine, 58:6, 191-192, DOI: 10.1080/00325481.1975.11714211 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714211
Published online: 07 Jul 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 08 August 2017, At: 16:30
case report
Downloaded by [Australian Catholic University] at 16:30 08 August 2017
NODULAR GLOMERULOSCLEROSIS IN A NONDIABETIC
In July 1974, a 55-year-old farmer was admitted co Christian Medical College Hospital, Vellore, South India, with swelling of the legs of six months' duration. The history and family history were noncontributory. Physical examination revealed bilateral pitting edema of the legs and slight puffiness of the face. Blood pressure was 134/84 mm Hg. Other findings of the clinical examinarion, including funduscopy, were normal. Fasting and two-hour postprandial blood glucose values per 100 ml were 80 and 92 mg, respectively. Urinalysis showed albuminuria, 4+; sugar, negative; and 5 to 7 white cells, 2 to 3 red cells, and numerous granular and epithelial casts per high-power field. Blood urea nitrogen level was 30 mg/ 100 ml, and 24hour urine albumin determination was 4.1 gm. Hemoglobin concentration, erythrocyte sedimentation rate, total leukocyte and differentiai counts, and serum complement, lipid, and electrolyte levels were within normal limits. Urine culture and lupus erythematosus cell rest results were negative, and the antistreptolysin-0 titer was normal. On a plain x-ray film of the abdomen, the kidneys were of normal size. Needle biopsy of the left kidney showed severe nodular glomerulosclerosis (figure 1) but no amyloid. Values measured in milligrams per 100 ml for the standard oral glucose tolerance test were: fasting 80, one-hour 130, two-hour 110, and three-hour 86. Those for a steroidprimed glucose tolerance test were: fasting 82, one-hour 140, two-hour 110, and threehour 86. Results of pancreatic and liver function tests and a needle biopsy specimen of the liver were normal. Furosemide, 40 mg twice a week, and a high-protein diet were prescribed, and the patient was discharged. In December 1974, the patient was readmitted for a biopsy of the right kidney, which also showed nodular glomerulosclerosis. Blood urea and serum creatinine levels and urinalysis results were more or less un-
Vol. 58 • No. 6 • November 1975 • POSTGRADUATE MEDICINE
S. K. SAMANTARAY, MD Christian Medical College Hospital Vellore, South lndia
changed. Results of a steroid-primed glucose tolerance test measured in milligrams per 100 ml were: fasting 78, one-hour 136, twohour 120, and three-hour 80. Funduscopy did not reveal any abnormality. The patient was discharged on the same regimen as before. Discussion
Since the original description of nodular glomerulosclerosis by Kimmelstiel and Wilson1 in 1936, this disorder bas been considered pathognomonic of diabetes mellitus. Although the lesion is known to occur without manifest diabetes, 2 ' 3 it is extremely rare in a nondiabetic. From results of innumerable autopsies and 600 kidney biopsies, Gellman and associates4 concluded chat nodular glomerulosclerosis occurs only in diabetes mellitus. However, diagnosis of diabetes on the basis of abnormal results on glucose tolerance testing in the presence of azotemia seems erroneous, as glucose intolerance is known to occur in renal failure per se. 5 It is possible chat many nondiabetic patients with uremie hyperglycemia were falsely included in the Gellman series. In fact, the specificity of nodular glomerulosclerosis for diabetes mellieus is questionable, as it is seen rarely without evidence of diabetes mellitus in hypertension,3'6 acute necrotizing pancreatitis, 6 chronic pancreatitis,7 alcoholic fatty liver8 and portal cirrhosis,8 ' 9 and nephrotic syndrome. 5 One can argue that this patient could still have diabetes without an abnormal glucose tolerance test result. Diabetes mellitus bas a metabolic and a vascular component which may be independent of each other. Hence, nodular glomerulosclerosis may be present prior to or independent of an abnormal glucose tolerance test result. 10 ~
191
~~-------------------llosone®
Wamlng Hepatic dyslunction with orwithout jaundice has occurred,chielly in adults, in association with erythromycln estolate administration. lt may be accompanied by malaise, nausea, vomiting, abdominal colle, and lever. ln some instances. severe abdominal pain may simulate an abdominal surgical emergency. Il the above lindings occur, discontinue llosone promptly. llosone is contraindicated lor patients with a known history of sensitivity to this drug and lor those with preexisting liver disease.
Downloaded by [Australian Catholic University] at 16:30 08 August 2017
Flpre 1. Biopsy specimen showing nodular glomerulosclerosis but no amyloid. (Hematoxylin-eosin stain, reduced from X250.)
Lifelong follow-up of the patient may show whether the lesion develops before glucose tolerance becomes abnormal. Rosenbaum and associates11 reported ultramicroscopie glomerular abnormalities in the prediabetic state, and if these changes represent the early stage of glomerulosclerosis, one may expect to see diabetic glomerulosclerosis without abnormal glucose tolerance. Address reprint requests to S. K. Samantaray, MD, Department of Medicine Firm III, Christian Medical College Hospital, Ida Scudder Rd, Vellore-4, Tamilnadu, South India.
REFERENCES 1. Kimmelstiel P, Wilson C: Intercapillary lesions in glomeruli of kidney. Am ] Pathol 12:83, 1936 2. Eilenberg M: Diabetic nephropathy without manifest diabetes. Diabetes 11 :197, 1962 3. Allen AC: So-called intercapillary glomerulosclerosis. Arch Pathol 32:33, 1941 4. Gellman DO, Pirani CL, Soothill JF, et al: Diaheric nephropathy: A clinical and pathological study based on renal biopsies. Medicine 38:321, 19~9 ~- Schreiner GE: Nephroric syndrome. In Strauss MB, Welt LG: (Editors): Diseases of Kidney. Ed 2. Boston, Little, Brown & Co, 1971, p ~64 6. Raphael SS, Mathew JG, Lynch MJ: KimmelsrielWilson glomerulonephropathy: Its occurrence in diseases other than diabetes mellitus. Arch Pathol 6~ :420, 19~8 7. Shapiro FL, Smith HT: Diaheric glomerulosclerosis in a patient with chronic pancreatitis. Arch Intern Med 117:79~. 1966 8. Lynch MJ, Raphael SS: The nature of diabetic glomerulosclerosis. Diabetes 6:488, 19~7 9. Horn RC Jr, Smetana H: Intercapillary glomerulosclerosis. Am ] Pathol 18:93, 1942 10. Harringron AR, Hare HG, Chambers WN, et al: Nodular glomerulosclerosis suspected during !ife in a patient without demonsuable diabetes mellitus. N Engl ] Med 275 :206, 1966 11. Rosenbaum P, Kattine AA, Gottsegen WL: Diaheric and prediabetic nephropathy in childhood. Am ] Dis Child 106:83, 1963
POSTGllADUATE MEDICINE invites submission of brief case reports for early publication. Illustrations and references should be included only when essenrial.
192
(erythromycin estolate)
lndlcatlona: Streptococcus pyogenes (Group A Beta-Hemolytic)-Upper and lower-respiratory-tract, skin, and soft-tissue infections of mild to moderate severity. Injectable benzathine penicillln G is considered by the American Heart Association to be the drug of chai ce in the treatment and prevention of streptococcal pharyngitis and in long-term prophylaxis of rheumatie lever. When oral medication is prelerred lor treating streptococcal pharyngitis, penicillin G or V or erythromycin is the alternate drug of choice. The importance of the patient's strict adherence to the prescribed dosage regimen must be stressed when oral medication is given. A therapeutic dose should be administered lor at least ten days. Alplla-Hemolytic Streptococci (Viridans Group)-Short-term prophylaxis against bacterial endocarditis prior to dental or other operative procedures in patients with a history of rheumatic lever or congenital heart disease who are hypersensitive to penicillin. (Erythromycin is not suitable prior to genitourinary surgery when the organisms likely to lead to bacteremia are gram-negative bacilll or belong to the enteracoccus group of streptococci.) Stapllylococcus aureus-Acute infections of skin and soft tissue which are mild ta moderately severe. Resistance may develop during treatment. Diplococcus pneumoniae-Upper and lower-respiratory-tract infections of mi id to moderate severity. Mycoplasme pneumoniae-ln the treatment of primary atypical pneumania when due to this organism. Treponema pallidum-As an alternate treatment in penicillin-allergic patients. ln primary syphilis, spinal-fluid examinations should be done belore treatment and as part of lollow-up alter therapy. Corynebacterium diplltlleriae-As an adjunct to antitoxin. to prevent establishment of camers. and to eradicate the organ1sm in camers. C. minutissimum-ln the treatment of erythrasma. Entamoeba llistotytica-ln the treatment of intestinal amebiasis only. Extraenteric amebiasis requires treatment with other agents. Listeria monocytogenes-lnfections due to this organism. Contralndlcatlon: Known hypersensitivity to this antibiotic. Warnlnga: (See Warning box above.) The administration of erythromycin estolate has been assoc:ated w:th the inlrequent occurrence of cholestatic hepatitis. Laboratory findings have been characterized by abnermal hepatic lunction test values, peripheral eosinophilia, and leuko· cytosis. Symptoms may include malaise, nausea, vomiting, abdominal cramps, and lever. Jaundice may or may not be present. ln sorne instances. severe abdominal pain may simulate the pain of biliary colic, pancreatitis, perlorated ulcer, or an acute abdominal surgical problem. ln ether instances. clinical symptoms and results of liver function tests have resembled findings in extrahepatic obstructive jaundice. Initial symptoms have developed in sorne cases alter a lew days of treatment but generally have followed one or Iwo weeks of continuous therapy. Symptoms reappear promptly, usually within forty-eight hours alter the drug is readministered to sensitive patients. The syndrome seems to result from a form of sensitization. occurs chiefly in adults, and has been reversible when medication is discontinued. Usage in Pregnancy-Salety of this drug lor use during pregnancy has not been established. Precautlona: Caution should be exercised in administering the anti· biotic to patients with impaired hepatic function. Adverae Reactlona: Dose-related abdominal cramping and discomfort, nausea, vomiting, and diarrhea have been noted. During prolonged or repeated therapy, there is a possibility of overgrowth of nonsusceptible bacteria or lungi. Il such infections arise, the drug should be discontinued and appropriate therapy instituted. Mild allergie reactions, su ch- as urticaria and ether skin rashes, have occurred. Serious allergie reactions, including anaphylax1s, have been reported. [o70374[ Additional information availab/e ta the profession on request. DISTA PRODUCTS COMPANY Division of Eli Lilly and Company ~00092 Indianapolis, Indiana 46206
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Nodular Glomerulosclerosis in a Nondiabetic S. K. Samantaray To cite this article: S. K. Samantaray (1975) Nodular Glomerulosclerosis in a Nondiabetic, Postgraduate Medicine, 58:6, 191-192, DOI: 10.1080/00325481.1975.11714211 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714211
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 08 August 2017, At: 16:30
case report
Downloaded by [Australian Catholic University] at 16:30 08 August 2017
NODULAR GLOMERULOSCLEROSIS IN A NONDIABETIC
In July 1974, a 55-year-old farmer was admitted co Christian Medical College Hospital, Vellore, South India, with swelling of the legs of six months' duration. The history and family history were noncontributory. Physical examination revealed bilateral pitting edema of the legs and slight puffiness of the face. Blood pressure was 134/84 mm Hg. Other findings of the clinical examinarion, including funduscopy, were normal. Fasting and two-hour postprandial blood glucose values per 100 ml were 80 and 92 mg, respectively. Urinalysis showed albuminuria, 4+; sugar, negative; and 5 to 7 white cells, 2 to 3 red cells, and numerous granular and epithelial casts per high-power field. Blood urea nitrogen level was 30 mg/ 100 ml, and 24hour urine albumin determination was 4.1 gm. Hemoglobin concentration, erythrocyte sedimentation rate, total leukocyte and differentiai counts, and serum complement, lipid, and electrolyte levels were within normal limits. Urine culture and lupus erythematosus cell rest results were negative, and the antistreptolysin-0 titer was normal. On a plain x-ray film of the abdomen, the kidneys were of normal size. Needle biopsy of the left kidney showed severe nodular glomerulosclerosis (figure 1) but no amyloid. Values measured in milligrams per 100 ml for the standard oral glucose tolerance test were: fasting 80, one-hour 130, two-hour 110, and three-hour 86. Those for a steroidprimed glucose tolerance test were: fasting 82, one-hour 140, two-hour 110, and threehour 86. Results of pancreatic and liver function tests and a needle biopsy specimen of the liver were normal. Furosemide, 40 mg twice a week, and a high-protein diet were prescribed, and the patient was discharged. In December 1974, the patient was readmitted for a biopsy of the right kidney, which also showed nodular glomerulosclerosis. Blood urea and serum creatinine levels and urinalysis results were more or less un-
Vol. 58 • No. 6 • November 1975 • POSTGRADUATE MEDICINE
S. K. SAMANTARAY, MD Christian Medical College Hospital Vellore, South lndia
changed. Results of a steroid-primed glucose tolerance test measured in milligrams per 100 ml were: fasting 78, one-hour 136, twohour 120, and three-hour 80. Funduscopy did not reveal any abnormality. The patient was discharged on the same regimen as before. Discussion
Since the original description of nodular glomerulosclerosis by Kimmelstiel and Wilson1 in 1936, this disorder bas been considered pathognomonic of diabetes mellitus. Although the lesion is known to occur without manifest diabetes, 2 ' 3 it is extremely rare in a nondiabetic. From results of innumerable autopsies and 600 kidney biopsies, Gellman and associates4 concluded chat nodular glomerulosclerosis occurs only in diabetes mellitus. However, diagnosis of diabetes on the basis of abnormal results on glucose tolerance testing in the presence of azotemia seems erroneous, as glucose intolerance is known to occur in renal failure per se. 5 It is possible chat many nondiabetic patients with uremie hyperglycemia were falsely included in the Gellman series. In fact, the specificity of nodular glomerulosclerosis for diabetes mellieus is questionable, as it is seen rarely without evidence of diabetes mellitus in hypertension,3'6 acute necrotizing pancreatitis, 6 chronic pancreatitis,7 alcoholic fatty liver8 and portal cirrhosis,8 ' 9 and nephrotic syndrome. 5 One can argue that this patient could still have diabetes without an abnormal glucose tolerance test result. Diabetes mellitus bas a metabolic and a vascular component which may be independent of each other. Hence, nodular glomerulosclerosis may be present prior to or independent of an abnormal glucose tolerance test result. 10 ~
191
~~-------------------llosone®
Wamlng Hepatic dyslunction with orwithout jaundice has occurred,chielly in adults, in association with erythromycln estolate administration. lt may be accompanied by malaise, nausea, vomiting, abdominal colle, and lever. ln some instances. severe abdominal pain may simulate an abdominal surgical emergency. Il the above lindings occur, discontinue llosone promptly. llosone is contraindicated lor patients with a known history of sensitivity to this drug and lor those with preexisting liver disease.
Downloaded by [Australian Catholic University] at 16:30 08 August 2017
Flpre 1. Biopsy specimen showing nodular glomerulosclerosis but no amyloid. (Hematoxylin-eosin stain, reduced from X250.)
Lifelong follow-up of the patient may show whether the lesion develops before glucose tolerance becomes abnormal. Rosenbaum and associates11 reported ultramicroscopie glomerular abnormalities in the prediabetic state, and if these changes represent the early stage of glomerulosclerosis, one may expect to see diabetic glomerulosclerosis without abnormal glucose tolerance. Address reprint requests to S. K. Samantaray, MD, Department of Medicine Firm III, Christian Medical College Hospital, Ida Scudder Rd, Vellore-4, Tamilnadu, South India.
REFERENCES 1. Kimmelstiel P, Wilson C: Intercapillary lesions in glomeruli of kidney. Am ] Pathol 12:83, 1936 2. Eilenberg M: Diabetic nephropathy without manifest diabetes. Diabetes 11 :197, 1962 3. Allen AC: So-called intercapillary glomerulosclerosis. Arch Pathol 32:33, 1941 4. Gellman DO, Pirani CL, Soothill JF, et al: Diaheric nephropathy: A clinical and pathological study based on renal biopsies. Medicine 38:321, 19~9 ~- Schreiner GE: Nephroric syndrome. In Strauss MB, Welt LG: (Editors): Diseases of Kidney. Ed 2. Boston, Little, Brown & Co, 1971, p ~64 6. Raphael SS, Mathew JG, Lynch MJ: KimmelsrielWilson glomerulonephropathy: Its occurrence in diseases other than diabetes mellitus. Arch Pathol 6~ :420, 19~8 7. Shapiro FL, Smith HT: Diaheric glomerulosclerosis in a patient with chronic pancreatitis. Arch Intern Med 117:79~. 1966 8. Lynch MJ, Raphael SS: The nature of diabetic glomerulosclerosis. Diabetes 6:488, 19~7 9. Horn RC Jr, Smetana H: Intercapillary glomerulosclerosis. Am ] Pathol 18:93, 1942 10. Harringron AR, Hare HG, Chambers WN, et al: Nodular glomerulosclerosis suspected during !ife in a patient without demonsuable diabetes mellitus. N Engl ] Med 275 :206, 1966 11. Rosenbaum P, Kattine AA, Gottsegen WL: Diaheric and prediabetic nephropathy in childhood. Am ] Dis Child 106:83, 1963
POSTGllADUATE MEDICINE invites submission of brief case reports for early publication. Illustrations and references should be included only when essenrial.
192
(erythromycin estolate)
lndlcatlona: Streptococcus pyogenes (Group A Beta-Hemolytic)-Upper and lower-respiratory-tract, skin, and soft-tissue infections of mild to moderate severity. Injectable benzathine penicillln G is considered by the American Heart Association to be the drug of chai ce in the treatment and prevention of streptococcal pharyngitis and in long-term prophylaxis of rheumatie lever. When oral medication is prelerred lor treating streptococcal pharyngitis, penicillin G or V or erythromycin is the alternate drug of choice. The importance of the patient's strict adherence to the prescribed dosage regimen must be stressed when oral medication is given. A therapeutic dose should be administered lor at least ten days. Alplla-Hemolytic Streptococci (Viridans Group)-Short-term prophylaxis against bacterial endocarditis prior to dental or other operative procedures in patients with a history of rheumatic lever or congenital heart disease who are hypersensitive to penicillin. (Erythromycin is not suitable prior to genitourinary surgery when the organisms likely to lead to bacteremia are gram-negative bacilll or belong to the enteracoccus group of streptococci.) Stapllylococcus aureus-Acute infections of skin and soft tissue which are mild ta moderately severe. Resistance may develop during treatment. Diplococcus pneumoniae-Upper and lower-respiratory-tract infections of mi id to moderate severity. Mycoplasme pneumoniae-ln the treatment of primary atypical pneumania when due to this organism. Treponema pallidum-As an alternate treatment in penicillin-allergic patients. ln primary syphilis, spinal-fluid examinations should be done belore treatment and as part of lollow-up alter therapy. Corynebacterium diplltlleriae-As an adjunct to antitoxin. to prevent establishment of camers. and to eradicate the organ1sm in camers. C. minutissimum-ln the treatment of erythrasma. Entamoeba llistotytica-ln the treatment of intestinal amebiasis only. Extraenteric amebiasis requires treatment with other agents. Listeria monocytogenes-lnfections due to this organism. Contralndlcatlon: Known hypersensitivity to this antibiotic. Warnlnga: (See Warning box above.) The administration of erythromycin estolate has been assoc:ated w:th the inlrequent occurrence of cholestatic hepatitis. Laboratory findings have been characterized by abnermal hepatic lunction test values, peripheral eosinophilia, and leuko· cytosis. Symptoms may include malaise, nausea, vomiting, abdominal cramps, and lever. Jaundice may or may not be present. ln sorne instances. severe abdominal pain may simulate the pain of biliary colic, pancreatitis, perlorated ulcer, or an acute abdominal surgical problem. ln ether instances. clinical symptoms and results of liver function tests have resembled findings in extrahepatic obstructive jaundice. Initial symptoms have developed in sorne cases alter a lew days of treatment but generally have followed one or Iwo weeks of continuous therapy. Symptoms reappear promptly, usually within forty-eight hours alter the drug is readministered to sensitive patients. The syndrome seems to result from a form of sensitization. occurs chiefly in adults, and has been reversible when medication is discontinued. Usage in Pregnancy-Salety of this drug lor use during pregnancy has not been established. Precautlona: Caution should be exercised in administering the anti· biotic to patients with impaired hepatic function. Adverae Reactlona: Dose-related abdominal cramping and discomfort, nausea, vomiting, and diarrhea have been noted. During prolonged or repeated therapy, there is a possibility of overgrowth of nonsusceptible bacteria or lungi. Il such infections arise, the drug should be discontinued and appropriate therapy instituted. Mild allergie reactions, su ch- as urticaria and ether skin rashes, have occurred. Serious allergie reactions, including anaphylax1s, have been reported. [o70374[ Additional information availab/e ta the profession on request. DISTA PRODUCTS COMPANY Division of Eli Lilly and Company ~00092 Indianapolis, Indiana 46206
