|Year : 2015 | Volume
| Issue : 1 | Page : 81-83
The old man with heavy proteinuria: An uncommon case of lupus nephropathy in elderly male
Somak Kumar Das1, Uttam Biswas1, Sanat Biswas2, Chanchal Kumar Jana3
1 Department of Medicine, College of Medicine and JNM Hospital, Kalyani, Nadia, India
2 Department of Pathology, R. G. Kar Medical College, Kolkata, West Bengal, India
3 Department of Medicine, R. G. Kar Medical College, Kolkata, West Bengal, India
|Date of Web Publication||8-Jan-2015|
Somak Kumar Das
2nd floor, A/14, Katjunagar, Jadavpur, Kolkata - 700 032, West Bengal
Source of Support: None, Conflict of Interest: None
Systemic lupus erythematosus is an autoimmune systemic disease, particularly affecting women of reproductive age group. Male lupus and associated nephropathy is very uncommon. Elderly male presenting with lupus nephropathy is still a rare finding in literature. We report a case of lupus nephropathy in a 67-year-old male presenting with heavy proteinuria. We also conclude that age and sex of a patient is no bar for lupus, and every physician must consider autoimmune disease even in elderly male patients.
Keywords: Lupus, male, membranous nephropathy
|How to cite this article:|
Das SK, Biswas U, Biswas S, Jana CK. The old man with heavy proteinuria: An uncommon case of lupus nephropathy in elderly male. Med J DY Patil Univ 2015;8:81-3
| Introduction|| |
Systemic lupus erythematosus (SLE) is a clinical syndrome with a wide array of symptoms and organs involved. Overall, 90% of patients with lupus are female, and most are pre-menopausal.  Early diagnosis is crucial to prevent potentially fatal complications. Male elderly patients with SLE are easily missed or delayed in diagnosis because of the lower incidence in these groups. Lupus in the elderly generally presents with a decreased incidence of dermatologic manifestations, arthritis, and renal involvement. Elderly male presenting with lupus nephropathy is still a rare finding in literature. We report a case of lupus nephropathy in a 67-year-old male presenting with heavy proteinuria.
| Case Report|| |
A 67-year-old male patient presented to our in-patient department with complaints of generalized swelling of whole body for last 2 months and shortness of breath for last 3 days. The patient was known to be hypertensive and was on amlodipine 5 mg/day and losartan 50 mg/day. He was also addicted to smoking with 8-9 cigarette/ day for last 30 years. He was non - diabetic and non-alcoholic. No history of fever, sputum expectoration, pain chest, palpitation, jaundice, oliguria, and hematuria were reported. On taking detailed history, patient's relative reported similar illness 6 months back. Moderate degree of anemia, generalized edema, and some maculo-papular erythematosus non-itchy rash over face were detected on general examination [Figure 1]. Jugular venous pressure was within normal limits. Systemic examinations were unremarkable, except few bilateral lung base fine crackles and mild free fluid in abdomen.
Routine blood examination revealed normochromic - normocytic anemia and very high erythrocyte sedimentation rate (ESR) of 110 mm in 1 st hour (Westergren method). Severe hypoproteinemia and hypoalbuminemia (Total serum protein - 3.4 gm/dl, and serum albumin - 1.4 gm/dl) without any elevation of liver enzymes and bilirubin were detected in liver function test. Renal function test showed mild azotemia (Serum urea - 71 mg/dl and serum creatinine - 1.76 mg/dl). Routine urinalysis expressed 4 + proteinuria, 3-4 pus cells, and 4-5 red blood cells per high power field. Twenty-four-hour collection of urine revealed 8.3 gm proteinuria. Serum electrolytes, fasting, and 2-hour glucose tolerance test were within normal limits, but serum triglyceride and low-density lipoprotein being 366 mg/dl and 156 mg/dl, respectively. A provisional diagnosis of nephrotic syndrome complicated with congestive heart failure was made. Investigations were sent to find out the etiology, and management of heart failure was imparted.
|Figure 1: Maculo-papular erythematosus non-itchy rash over malar area of face|
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Hepatitis virus profile for hepatitis B and C and human immunodeficiency virus (HIV) screening test were non-reactive. Echocardiography report was unremarkable, except mild diastolic dysfunction. Ultrasonography (USG) of abdomen revealed mild ascites. Renal biopsy was performed, and pathologist reported "Membranous glomerulonephritis" [Figure 2].
|Figure 2: Light Microscopic low power and high power view showing thickened capillary walls and increased messangeal matrix indicating "Membranous glomerulonephritis"|
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As we initially did not consider any immunologic disease in this elderly male patient, anti-nuclear antibody (ANA) and other autoantibodies were not tested. Later on, ANA was found to be positive in 1:640 titer with speckled pattern in Hep2 cell line, and anti-ds DNA was also found to be positive. Immuno-staining of renal biopsy sample confirmed SLE (Stage - V SLE nephropathy).
Patient was then treated with pulse methylprednisolone 1 gm per day for 3 days and followed by pulsed cyclophosphamide therapy. Patient responded well with significant reduction in generalized swelling, and repeat 24-hour urine protein became 580 mg after 1 month.
| Discussion|| |
Systemic lupus erythematosus (SLE) is an autoimmune inflammatory systemic disease involving multiple organs. Although SLE is considered a disease occurring primarily in pre-menopausal females, several investigators have examined this disease in the elderly population. Female predominance usually observed in earlier-onset lupus is 8-9:1, compared with approximately 7:1 seen with lupus in the elderly. The onset of lupus generally occurs between the ages of 15 and 25 years; however, SLE has been diagnosed and studied in individuals up to 85 years of age. 
Clinical investigators have generally defined lupus in the elderly as diagnosis of SLE after the age of 50. Late-onset lupus differs from early-onset lupus in gender and ethnic prevalence, clinical presentation, pattern of organ involvement, severity of disease, and prognosis. These differences are due to age-related variation in environmental and/or host factors responsible for disease expression and to variation in sex hormones. 
The mean age of onset of lupus in the elderly is usually in the sixth or seventh decade of life. Probably, an initial incorrect diagnosis is the main reason to this delay. One study reviewing diagnosis of late-onset lupus found that in greater than 50% of cases reviewed, the initial diagnostic impression was not SLE.  Elderly patients diagnosed with SLE generally have a milder and more benign clinical presentation. Classically, late-onset lupus presents with a greater frequency of pulmonary involvement and a decreased frequency of polyarthritis, alopecia, lymphadenopathy, severe nephritis, and central nervous system (CNS) disease, although many clinical manifestations have been observed. 
Aging is generally associated with increased antinuclear antibodies (ANA) and other autoantibodies. In elderly patients with SLE, several other significant serological findings can be helpful in making the diagnosis of lupus in this population. Another important finding is an increased frequency of anti-Ro (SSA) and/or anti-La (SSB) antibodies in late-onset lupus. These antibodies may pose a useful diagnostic aid for lupus in the elderly and suggest that their presence may represent a link between SLE and Sjφgren's syndrome. Other serological findings associated with lupus in the elderly include hypocomplementemia and increased frequency of IgM anticardiolipin antibodies, anti-phospholipid antibodies, and rheumatoid factor. 
The treatment course in late-onset lupus has been shown to vary, but usually is directed by disease manifestations. Treatment strategies do not differ widely from those seen in younger patients. The greater risks for adverse side-effects associated with treatments such as corticosteroids and/or immunosuppressive agents lead doctors to often avoid their use. Older persons are more likely to have multiple diseases and be taking multiple medications, which can lead to more drug-drug interactions, drug-induced disease, and adverse drug reactions. Prevalence of glomerulonephritis and nephritic proteinuria are reduced in late-onset SLE compared with younger onset; however, it still complicates the course of disease in 20%-25% of subjects. Albuminuria-proteinuria relationships are different in SLE GN compared with that of other forms of Chronic Kidney Disease (CKD). Renal tubular albumin retrieval could differ between SLE and other CKD conditions. Albumin is modified in SLE. Hypoalbuminuria independent of urine protein loss commonly occurs in SLE. The apparent mechanism is inflammation-induced albumin catabolism. This mechanism could influence albuminuria-proteinuria relationship in SLE GN compared with that of other causes of CKD, in which inflammation is not a prominent feature. ,
Because a risk of renal failure exists, a treatment regimen of corticosteroids and intravenous pulse cyclophosphamide is sometimes administered. Cyclophosphamide works by depleting B and T lymphocytes and modulating T-cell activation responses and B-cell antibody production. It is primarily recommended as pulse therapy for focal and diffuse lupus nephritis and is usually dosed monthly for 6 months, and then every 3 months for a period of 1 year after remission of nephritis is achieved. Although potentially fatal side-effect is unusual, patients over age 50 are at increased risk of cardiotoxicity and should be monitored closely. 
In our case, we ultimately diagnosed SLE according to the new revised American College of Cardiology (ACR)/ European League against Rheumatism (EULAR) classification criteria where renal biopsy suggestive of lupus and positive ANA and/or Anti- ds-DNA clinched the diagnosis.
| Conclusion|| |
The specialty of this case of elderly male lupus nephropathy with nephrotic range proteinuria, reported by us is that it provides us with few learning matters. Every physician and nephrologist must be aware of the fact that lupus doesn't discriminate by age, sex, or race. SLE does occur in elderly males. Late-onset lupus nephropathy in elderly male must be considered in differential diagnosis of nephrotic proteinuria, whatever may be the age, sex, or race of the patients. We should think beyond diabetic and / or hypertensive nephropathy regarding nephrotic range proteinuria. Moreover, this is one example of application of new classification criteria of lupus. We think, many clinician encountered similar case in the past, but unable to classify as lupus because of previous complex criteria.
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[Figure 1], [Figure 2]