Gross hematuria as an unusual manifestation of membranous nephropathy

Abstract

 Membranous nephropathy (MN) often shows covert onset, accompanied with edema, microscopic hematuria or asymptomatic proteinuria, but rarely with gross hematuria. A Japanese 4-year-old girl was referred for evaluation of proteinuria and gross hematuria. No family members had renal diseases. Urinalysis showed massive proteinuria and dark-colored urine containing many red blood cells. Laboratory investigations included serum creatinine of 0.4mg/dl, low serum total protein of 5.9g/dl, and elevated total cholesterol of 243mg/dl. Serum complement levels were normal. Anti-DNA antibodies and hepatitis B antigen were negative. Urine culture showed no growth. The SAS Adeno Test (SA Scientific, San Antonio, TX, USA) confirmed human adenovirus infection. A biopsied kidney specimen contained 50 glomeruli. The glomerular basement membrane appeared normal with the absence of mesangial proliferation. The tubules and the interstitium were normal. Immunofluorescence showed diffuse coarse granular staining of IgG and C3 along all the capillary walls. Electron microscopy showed epithelial deposits located beneath the foot process, and normal lamina densa without spiky projections. She received oral prednisolone and imidaprilhydrochloride, and then proteinuria promptly disappeared but isolated microscopic hematuria still persisted. We describe a female child with gross hematuria and proteinuria following adenoviral infection, whose renal biopsy specimen showed typical MN, and we discuss the possible association between adenovirus and MN.