Postgraduate Medical Journal (November 1983) 59, 730-733

Immune complex glomerulonephritis and chronic anaerobic urinaryinfection-complications of filariasis

A. D. ORMERODM.B., M.R.C.P.

J. PETERSENM.B., M.R.C.P.

J. K. HUSSEYM.B., F.R.C.R.

J. WEIRM.B., M.R.C.P., F.R.C.R.

N. EDWARDM.B., F.R.C.P.E.

Departments of Medicine and Radiology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen

SummaryWe describe a patient with chyluria due to abdominalBancroftian Mfiariasis. The patient showed two un-usual complications, an immune complex glomerulo-nephritis and a chronic urinary infection. We alsodiscuss the use of the CT whole body scanner in thediagnosis and delineation of the extent of the disease.

KEY WORDS: filariasis, glomerulonephritis, urinary tract infection.

IntroductionChyluria is a frequent and well established compli-

cation of filariasis and is caused by fistulous connec-tions between diseased lymphatic vessels and theurinary tract. More recently, there have been severalreports of immune complex glomerulonephritis inpatients with filariasis (Date, Shastry, and Johny,1979b; Waugh, Alexander and Ibels, 1980). Theimmune complexes are thought to be formed inresponse to the parasitic antigen. Similar glomerularchanges have been induced in animal models (Klei,Crowell and Thompson, 1974). Ascending lymphan-giography forms an essential part ofthe investigationof chyluria but may also be aided by concurrentcomputerized tomographic (CT) whole body scann-ing; we report our findings using these techniques.We also discuss the factors that may have, given riseto the unusual complication of chronic anaerobicurinary infection.

Case reportThe patient, a Caucasian, aged 17 years, was born

in the Persian Gulf. Educated in the United King-dom he had spent about 3 months each year on

vacation in the Persian Gulf. At 13 years, whilst inAbu Dhabi, he suffered an undiagnosed pyrexialillness with delirium, which resolved spontaneouslyafter 3 days. From the age of 14 years, he hadrecurrent episodes of milky urine and occasional loinpain. He passed debris in the urine which resembledtissue and which sometimes interrupted the stream,but had no frequency, dysuria, urticaria, orchitis oroedema.

Physical examination was normal. There was nofever, rash, lymphadenopathy, splenomegaly, pleuraleffusion, ascites or oedema. The patient's urine wasyellow and milky.

Analysis of the urine revealed the presence ofprotein, blood and chylomicrons. The amount ofproteinuria was 3 g/day with a glomerular electro-phoretic pattern. The deposit contained lymphocytes,red cells and organisms but no polymorphonuclearleucocytes. Urine was sterile on routine culture, butculture for anaerobes revealed a mixed growth ofanaerobes including Bacteroides melaninogenicus,Bacteroides fragilis, Peptococcus prevotii and Pro-prionibacterium granulosum. There were no filariae inthe urine nor were filariae found on thick and thinblood films or by micropore concentration techniquescarried out on diurnal specimens of blood. Filarialimmunofluorescent antibody test and schistosomalenzyme-linked immunosorbent assay were negative.Haemoglobin was 15-6 g/dl, white cell count

2-4 x 109/litre with 4% eosinophils. Blood urea, elec-trolytes, creatinine, liver function tests, plasma lipids,immunoglobulins and serum complement were nor-mal. Autoantibodies were not present, ASO titre wasless than 160, blood cultures and Mantoux test werenegative. Intravenous pyelography was normal. Cys-

0032-5473/83/1100-0730 $02.00 i 1983 The Fellowship of Postgraduate Medicine

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Clinical reports 731:i,,~~~~~~~~~~JI"A

FIG. 1. Electron micrograph of part of a glomerulus showing a hypercellular mesangial lesion in which there are dense deposits (circled) ofimmune complex type (x 6175).

toscopy showed heaping up of one area of mucosa,histology of which showed cystitis cystica.

In view of the degree of proteinuria, the presenceof red cells in the urine and a depressed creatinineclearance (69 ml/min), a renal biopsy was carriedout. It showed focal, mild hypercellularity of somecapillary loops with the presence of red cells in thetubules. Electron microscopy showed minor mesan-gial hypercellularity with an increase in the mesan-gial matrix. In the mesangial regions of all glomeruliexamined, immune complexes were present (Fig. 1).There was focal fusion of foot processes. Tubularchanges were present with cell damage and indivi-dual cell death. Debris and fibrin were present in thetubules.

Ascending lymphangiography showed a remar-kable degree of abnormality of the lymphaticsproximal to the inguinal nodes, with tortuosity anddilatation notably around the bladder and left kidney(Fig. 2). The abdominal lymph nodes were notdemonstrated and the lipiodol contrast did not passinto the calyces of the kidney.A CT scan performed 48 hr after the lymphangio-

gram showed multiple dilated lymphatic channels upto 5 mm in diameter, extending into the mesentry,

porta hepatis and splenic hilum. The spleen wasenlarged to 2-3 times the normal size. Lymph nodeswere not enlarged (Fig. 3).The patient was treated with penicillin, 500 mg

four times daily, and metronidazole, 400 mg threetimes daily, for 2 weeks, with considerable improve-ment in the appearance of the urine which wasrendered sterile and protein free. He was then givendiethylcarbamazine in a dose of 2 mg/kg bodyweight for 3 weeks. On treatment, there was noevidence of an allergic reaction, no eosinophilia orfever. At review, he continues in his longest remissionof 6 months free from urinary abnormality.

Discussion

The diagnosis of Bancroftian filariasis was madefrom the history of residence in an endemic area,exclusion of other causes of chyluria and the classicalappearances of the lymphangiogram (Ko Ko, Ayeand Aung, 1975). The absence of antibodies tofilariae and of demonstrable parasites indicate onlythat the infection is inactive and is not inconsistentwith the diagnosis. Chyluria is a late complication ofthis disease which usually develops after the worms

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732 Clinical reports

FIG. 2. (a) Ascending lymphangiogram showing grossly abnormal dilated, tortuous lymphatics in the region of the bladder; (b) dilatedlymphatics in the region of the left kidney.

....

FiG. 3. Abdominal computerized axial tomography scan showingcontrast within dilated lymphatics (arrowed) extending into the root

of the mesentry.

have been eliminated by treatment or by the immuneresponse (Koo and Van Langenberg, 1969).Lymphangiography is valuable in the diagnosis of

the disease and may have a therapeutic effect.Akisada and Tani (1968) reported improvement in 18of 25 patients following lymphangiography. Thewhole body CT scanner was particularly useful inexcluding malignant enlargement of the abdominallymph nodes. In severe persistent chyluria, losses offat and protein can lead to severe wasting of the bodyand weight loss. In such cases, treatment by surgicaldisconnection of the lymphatics from the renal tractis often successful (Koo and Van Langenberg, 1969;Waugh et al., 1980). The CT whole body scannermay prove useful in determining the extent of thedisease prior to surgery.The patient's renal biopsy showed a minor mesan-

gioproliferative glomerulonephritis with evidence ofmesangial immune complex deposition, mild mesan-gial cell proliferation and focal podocyte fusion.After the exclusion of other potential causes, this is

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733 Clinical reports

thouht to have arisen as a consequence of theaatigenic stimulation of the filarial infection. Similarcha*es occurring in filariasis have been reportedelswhere (Date et al., 1979a, 1979b; Waugh et al.,1980). Waugh et al, also reported IgG, IgM and C3deposition in the capillary wall and mesangium.lectron dense deposits representing immune com-

plex deposition were also present. Similar findingshave been produced experimentally in animalmodels of filariasis (Klei et al, 1974). The exactmechanism of immune complex deposition remains

lative (Wilson and Dixon, 1981).In addition, the patient we describe was unusual in

having a chronic anaerobic urinary infection. WesUMst that these organisms passed from the colon,throgh the abnormal lymphatics to the urinary tract.As there is retrograde flow in the lymphatics organ-isms may bypass the lymph nodes. Experimentalocclwsion of the renal lymphatics renders the kidney

prone to infection (Murphy et at, 1959). Thistedency to infection may have been increased by thedepletion of lymphocytes in the chyluria and thenmutropenia resulting from splenomegaly. The infec-tion has not recurred since therapy with metronida-iole, We suggest that anaerobes are specificallysought in patients with chyluria as they may not bedisobvered on routine aerobic culture.

Acknowledgments

We are indebted to Dr H. G. Smylie for his help in thebacteriological assessment of the patient.

References

AKISADA, M. & TANI, S. (1968) Filarial chyluria in Japan. Radio-logy, 90, 31 1.

DATE, A., GUNASEKARAN, V., KIRUBAKARAN, M.G. & SHASTRY,J.C.M. (1979a) Acute eosinophilic glomerulonephritis with Ban-croftian filariasis. Postgraduate Medical Journal, 55, 905.

DATE, A., SHASTRY, J.C.M. & JOHNY, K.V. (1979b) Ultrastructuralglomerular changes in filarial chyluria. Journal of TropicalMedicine and Hygiene, 82, 150.

KLEI, T.R., CROWELL, W.A. & THOMPSON, P.E. (1974) Ultrastructu-ral glomerular changes associated with ifiariasis. American Journalof Tropical Medicine and Hygiene, 18, 608.

Ko Ko, U., AYE, T.T. & AUNG, S.T.T. (1975) Chyluria. ClinicalRadiology, 26, 237.

Koo, C.G. & VAN LANGENBERG, A. (1969) Chyluria, a clinicalstudy. Journal of the Royal College of Surgeons ofEdinburgh, 14,31.

MURPHY, J.J., SCHOENBERG, H.W., RATrNER, W.H. & Scorr, R.H.(1959) The role ofthe lymphatic system in pyelonephritis. SurgicalForum, 10, 880.

WAUGH, D.A., ALEXANDER, J.H. & IBELS, L.S. (1980) Filarialchyluria associated glomerulonephritis and therapeutic considera-tions in the chyluric patient. Australia andNew Zealand Journal ofMedicine, 10, 559.

WILSON, C.B. & DIXON, F.J. (1981) The Kidney (Eds. B. M. Brennerand F. C. Rector), 2nd edn. p. 1237. Saunders, Philadelphia.

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