eMedicine Specialties > Nephrology > Glomerular Diseases
Glomerulonephritis, Nonstreptococcal Associated With Infection
Updated: Dec 15, 2008
Introduction
Background
The classic association of glomerulonephritis (GN) with infection is poststreptococcal GN, usually developing after streptococcal pharyngitis (see Glomerulonephritis, Poststreptococcal). However, a number of glomerular diseases are associated with other bacterial, viral, fungal, and parasitic diseases.
Pathophysiology
Most glomerular diseases associated with infection are mediated by the immune complex. The classic example observed in poststreptococcal GN involves an antigen-antibody reaction, which may occur in the circulation or in the glomerulus. Deposition in the glomerulus results in activation of the complement cascade, which may involve either the classic or alternative pathway. The immune complexes may activate endogenous glomerular cells. The reduction of chemotactic factors results in the accumulation of leukocytes and platelets within the glomerulus and, consequently, the inflammatory response.
Several possible pathogenic events occur in viral diseases associated with glomerular injury. These may include the formation of circulating immune complexes involving viral antigens and antibodies, formation of circulating immune complexes induced by the release of antigens following virally induced cellular injury, formation of in situ antigen-antibody reactions or cell-mediated injury, and autoimmune reactions to glomerular structures induced by the virus.
In protozoal infections, such as malaria, antibodies are formed against malarial antigens. The circulating immune complexes activate complement and macrophages. The complexes are primarily deposited in subendothelial areas. A cell-mediated immune response may also occur.
Frequency
United States
The various causes of infection-related GN have different prevalence rates. In endocarditis, associated GN may occur in up to 20% of cases. Staphylococcus aureus has become a more common cause of GN than Streptococcus in developed countries. GN associated with hepatitis C is becoming a far more commonly recognized cause of GN.
International
Although specific numbers for incidence statistics are not available, in certain developing areas of the world, hepatitis B, HIV disease, malaria, and schistosomiasis are major causes of glomerulopathy.
Mortality/Morbidity
Depending on the etiology, the outcome of GN associated with infection can be quite variable.
- In GN associated with bacterial endocarditis, renal function returns after treatment with antibiotics. The GN usually resolves after the infection has cleared, with renal function beginning to improve within 1-2 weeks, complement levels normalizing within 6 weeks, and hematuria normalizing in approximately 6 months.
- The course of GNs associated with viral infection is more variable, although patients with HIV nephropathy commonly progress to end-stage renal disease.
Race
This condition is not limited to any particular race.
Sex
In most GNs associated with infection, no sexual predilection exists. However, HIV-associated GN is far more common in males.
Age
This type of GN can occur at any age.
Clinical
History
Presentation may vary from asymptomatic hematuria to a full-blown acute nephritic syndrome consisting of proteinuria, edema, hypertension, and renal failure.
- Hematuria may be gross or microscopic.
- Patients may have evidence of edema.
- Patients may report fever, night sweats, and rigors.
- Weight loss is a possible complaint.
- Patients may report arthralgias.
- Abdominal, chest, or back pain may be caused by a visceral abscess.
- Patients may have history of shunt placement for hydrocephalus, or they may have a vascular graft that has become infected.
- Patients with hepatitis B or C may have a history of intravenous drug abuse, needle stick injury, blood transfusions, or sexual promiscuity.
- Patients with HIV infection may have history of intravenous drug abuse, hemophilia, history of blood transfusion from 1977-1985, unprotected sex with multiple partners, or tuberculosis.
Physical
- Hypertension may be due to renal failure.
- Edema due to nephrotic syndrome is unusual but can develop in as many as 30% of cases associated with shunt nephritis.
- Rash may be maculopapular or purpuric.
- Lymphadenopathy is a reported finding.
- Patients may have hepatosplenomegaly.
- Findings of subacute bacterial endocarditis (SBE) may include the following:
- Heart murmur
- Purpura
- Roth spots
- Janeway lesions
Causes
Infections with bacteria, viruses, protozoa, and helminths can cause postinfectious GN (PIGN).
- Bacterial endocarditis: PIGN occurs more commonly in subacute rather than acute endocarditis. S aureus is now the most common pathogen recognized.
- Shunt nephritis: This may be associated with ventriculovascular, ventriculoperitoneal, peritoneovascular, or vascular shunts.
- Visceral abscesses: These may occur with abdominal, pulmonary, or retroperitoneal abscesses.
- Syphilis
- Hepatitis B
- Hepatitis C
- Human immunodeficiency virus
- Cytomegalovirus
- Parvovirus B19
- Hantavirus
- Malaria
- Schistosomiasis
- Leishmaniasis
- Filariasis
- Hydatid disease
- Toxoplasmosis
- Aspergillosis
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References
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Tang S, Lai FM, Lui YH, et al. Lamivudine in hepatitis B-associated membranous nephropathy. Kidney Int. Oct 2005;68(4):1750-8. [Medline].
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Further Reading
Keywords
glomerular diseases associated with infection, glomerular disease, infection-related glomerulonephritis, GN, postinfectious glomerulonephritis, PIGN, bacterial infection, viral infection, protozoal infection, helminth infection, bacterial endocarditis, shunt nephritis, visceral abscesses, syphilis, hepatitis B, hepatitis C, human immunodeficiency virus, HIV, cytomegalovirus, CMV, parvovirus B19, Hantavirus, malaria, schistosomiasis, leishmaniasis, filariasis, hydatid disease, toxoplasmosis, aspergillosis
