a 61-year - old man came to the hospital complaining of bilateral flank pain . left flank pain began approximately a month earlier , followed by right flank pain 4 days later . the patient also complained of dyspnea on exertion , urinary frequency , and foamy urine . he was diagnosed with hypertension 15 years prior and had taken traditional korean herbal medicines , such as acanthopanax , phellinus , licorice root , and steamed red ginseng . one week before coming to our hospital , he visited a local ophthalmologic clinic for bilateral floater symptoms and was diagnosed with anterior uveitis and treated with systemic and topical steroids . laboratory tests conducted at the hospital showed a blood urea nitrogen of 26 mg / dl ( the upper limit of normal ) , a serum creatinine of 2.3 mg / dl , and an estimated glomerular filtration rate ( gfr ) of 30.9 ml / min ( normal , 80 to 120 ml / min ) . a kidney biopsy specimen revealed diffuse interstitial infiltration of lymphocytes and eosinophils and mild tubular atrophy with focal fibrosis of the interstitium ( fig . systemic administration of prednisolone 1 mg / kg / day was started and slowly tapered ; furosemide and carvedilol were added for blood pressure control . the patient 's visual acuity was 20 / 20 in the right eye and 20 / 25 in the left eye . a slit lamp examination showed a mild degree ( 1 + to 2 + ) of inflammatory cells in the anterior chamber of both eyes ; however , synechia of the iris was not observed . based on these findings , a diagnosis of tinu syndrome was made , and the patient was treated with a topical steroid ( pred forte ; allergan , irvine , ca , usa ) for anterior uveitis . tinu syndrome is reportedly three times more common in women than in men , with a median age at onset of 15 years ( range , 9 to 74 years ) . although diagnosis of tinu syndrome is uncommon after 61 years of age , we experienced a patient with such a case . generally , renal involvement in tinu is mild ; however , in our patient the grf decreased to well below the normal range . failure to detect the disease earlier may have been the possible cause of the renal impairment . several medications , such as antibiotics and non - steroidal anti - inflammatory drugs , have been reported as a cause of tinu syndrome . using traditional korean medicines for 9 years tinu is an uncommon disease and is primarily a diagnosis by exclusion ; symptoms are associated with both uveitis and interstitial nephritis . general symptoms with tinu include fever ( 53% ) , weight loss ( 47% ) , general weakness and malaise ( 44% ) , and anorexia ( 28% ) . ocular effects seen with uveitis are limited to the anterior chamber in approximately 80% of cases ; both eyes are affected in 77% of cases . posterior uveitis can sometimes be seen . in most cases ( 65% ) , nephritis precedes uveitis ; however , in 21% of cases , uveitis is present before nephritis , and in 15% the two conditions occur simultaneously . symptoms associated with nephritis are typical of acute interstitial nephritis , such as flank pain , pyuria ( mainly sterile ) , hematuria , and proteinuria ( which is less severe than seen with nephrotic syndrome ) an association with human leukocyte antigens has been mentioned in some reports , as well as sensitization of common antigens located both in the eye and the kidney as possible pathologic processes of tinu . in addition to hypersensitivity reactions , the causative drug may act as a hapten , inducing cytokine production or vasculitis . another possible etiology is cross reactivity of active transporters that are inhibited by carbonic anhydrase inhibitors in both the renal tubule and ciliary epithelium . eosinophilia , elevated c - reactive protein , elevated erythrocyte sedimentation rate , normocytic normochromic anemia , and abnormal liver function tests are among the possible findings . in addition , anti - neutrophil cytoplasmic antibody , anti - nuclear antibody , and rheumatoid factor may be positive , and complement levels may be decreased . in the present case , all laboratory findings were within the normal range except for kidney function . in the absence of proteinuria and pyuria , detection of beta-2 microglobulin in the urine the degree of proximal or distal tubular dysfunction may not be directly proportional to the decrease in gfr . tubulointerstitial edema and infiltration can be observed in kidney biopsy under a light microscopy , while the glomerulus and blood vessels are relatively normal ; this is consistent with the present case . infiltration with lymphocytes , plasma cells , and histiocytes may be observed , and in 34% of cases , eosinophils . immunofluorescent findings are negative for antibody or complement in 86% of cases ; similarly , no antibodies or complements were detected in our patient . the differential diagnosis of tinu includes sarcoidosis , sjogren 's syndrome , behcet 's disease , wegener 's granulomatosis , systemic lupus erythematosis , hyperthyroidism , primary hyperparathyroidism , and infectious diseases ( e.g. , tuberculosis , brucellosis , toxoplasmosis , and herpes ) . tinu is often not recognized and affected patients often fail to seek medical care , making the prevalence of the disease appear less than in actuality . topical steroids are commonly recommended as the treatment of choice of anterior uveitis . during the initial attack , topical steroids are usually sufficient to control the inflammation . based on published case reports , ocular symptoms resolved in 3 months in 44% of cases while symptoms persisted for more than 3 months in 14% of cases if the inflammation is not controlled with steroids or if steroid use is contraindicated or not tolerated , immunosuppressive agents such as azathioprine or methotrexate may be considered . a diagnosis of tinu should be considered in patients with idiopathic uveitis presenting with renal disease even in elderly patients . as tinu is diagnosed by exclusion , a kidney biopsy and a thorough ophthalmologic examination are needed . once the diagnosis of tinu is made , immediate steroid therapy is necessary together with a collaborative approach to treatment by an internist and an ophthalmologist .