Membranous nephropathy superimposed on Churg-Strauss syndrome
A 37-year-old man was treated for Churg-Strauss syndrome 6 years back. It was diagnosed when he had history of problems such as breathlessness, wheezing, sticky sputum, weight loss, and myalgias. He also had history of cough and expectoration. He had these symptoms for 10 years before that presentation. He had joint pains, particularly metacarpophalangeal, interphalangeal, and wrist joints. He complained of subcutaneous nodules over upper and lower limbs. He also had rhinorrhea and later he was found to have nasal polyp. He had no symptoms such as abdominal pain, diarrhea, gastrointestinal bleeding, weakness of limbs and symptoms related to stroke, ophthalmologic involvement, and cardiac failure. His previous investigations are reported in .\nAt present, he complained of facial puffiness which gradually progressed to entire body. There was no antecedent history of fever or skin disease. There was history of increased frothiness of urine. There was no history of oliguria and hematuria. He also complained of breathlessness, wheezing, cough, and expectoration, particularly in the morning. His blood pressure was 160/90 mm of Hg. The present investigations are reported in .\nOn light microscopy, kidney biopsy revealed the following: 15 glomeruli, 3 sclerosed, and 5 showed focal necrosis and cellular crescents. Glomeruli showed diffuse thickening of glomerular basement membrane []. Spikes were present. Tubules, vessels, and interstitium were unremarkable. Immunofluorescence assay revealed: IgG 3+, IgM 1+, κ 1+, and λ 1 + in glomeruli. Electron microscopy was not performed. HbsAg Hepatitis B surface antigen and anti-HCV anti- hepatitis C virus antibodies were negative. Human immunodeficiency virus was non-reactive. Cytoplasmic antineutrophilic cytoplasmic antibody cANCA, anti nuclear antibody ANA, and anti double stranded DNA antibody anti-dsDNA were negative. Complements were within normal limits.\nAt first presentation, he was treated with methylprednisolone 15 mg/kg/d intravenous for 3 days followed by oral prednisolone 0.5 mg/kg/d for 3 months and was tapered to 10 mg/day by 6 months. He was continued on that dose, till the present complaints.\nAt present, he received intravenous methylprednisolone 15 mg/kg/d intravenous for 3 days followed by intravenous cyclophosphamide 500 mg and oral prednisolone 0.5 mg/kg/d. He also received monthly doses of intravenous cyclophosphamide 500 mg for 6 months. At the end of 6 months, azathioprine (2 mg/kg/d) was started and angiotensin-converting inhibitors and angiotensin receptor blockers were continued. After 18 months of follow-up, the proteinuria was 0.2 g/day, RBCs in urine were absent, and serum creatinine was 1.2 mg/dl.