Immunoglobulin A nephropathy associated with Plasmodium falciparum malaria.

Abstract

Glomerulonephritis occurs as a rare form of renal manifestation in Plasmodium falciparum malaria. Herein, we report a case of falciparum malaria-associated IgA nephropathy for the first time. A 49-yr old male who had been to East Africa was diagnosed with Plasmodium falciparum malaria. Microhematuria and proteinuria along with acute kidney injury developed during the course of the disease. Kidney biopsy showed mesangial proliferation and IgA deposits with tubulointerstitial inflammation. Laboratory tests after recovery from malaria showed disappearance of urinary abnormalities and normalization of kidney function. Our findings suggest that malaria infection might be associated with IgA nephropathy.

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© 2012 The Korean Academy of Medical Sciences.
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pISSN 1011-8934
eISSN 1598-6357
Immunoglobulin A Nephropathy Associated with Plasmodium
falciparum Malaria
Glomerulonephritis occurs as a rare form of renal manifestation in Plasmodium falciparum
malaria. Herein, we report a case of falciparum malaria-associated IgA nephropathy for
the first time. A 49-yr old male who had been to East Africa was diagnosed with
Plasmodium falciparum malaria. Microhematuria and proteinuria along with acute kidney
injury developed during the course of the disease. Kidney biopsy showed mesangial
proliferation and IgA deposits with tubulointerstitial inflammation. Laboratory tests after
recovery from malaria showed disappearance of urinary abnormalities and normalization
of kidney function. Our findings suggest that malaria infection might be associated with
IgA nephropathy.
Key Words: Glomerulonephritis; IgA nephropathy; Malaria; Plasmodium falciparum
Dong Eun Yoo1, Jeong Ho Kim2,
Jeong Hae Kie3, Yoonseon Park2,
Tae Ik Chang2, Hyung Jung Oh1,
Seung Jun Kim1, Tae-Hyun Yoo1,
Kyu Hun Choi1, Shin-Wook Kang1,
and Seung Hyeok Han1
1Department of Internal Medicine, Yonsei University
College of Medicine, Seoul; Departments of
2Internal Medicine and 3Pathology, National Health
Insurance Corporation Ilsan Hospital, Goyang, Korea
Received: 4 October 2011
Accepted: 12 December 2011
Address for Correspondence:
Seung Hyeok Han, MD
Department of Internal Medicine, Yonsei University College of
Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea
Tel: +82.2-2228-1975, Fax: +82.2-393-6884
E-mail: hansh@yuhs.ac
http://dx.doi.org/10.3346/jkms.2012.27.4.446 • J Korean Med Sci 2012; 27: 446-449
CASE REPORT
Nephrology
INTRODUCTION
Malaria is one of the most common parasitic infection in tropi-
cal areas, and 243 million cases were reported worldwide in
2008 (1). Renal involvement is particularly common in Plasmo-
dium malariae and Plasmodium falciparum infections and is
generally manifested as chronic progressive glomerulopathy in
the former and acute kidney injury (AKI) in the latter (2). In en-
demic areas, AKI occurs as a complication of falciparum malar-
ia, mostly caused by acute tubular necrosis (ATN) and/or inter-
stitial nephritis, in 1% to 4.8% of native patients, and its inci-
dence increases up to 25% to 30% in European patients. Anoth-
er less common form of renal involvement in falciparum ma-
laria is acute glomerulonephritis, which is characterized by
mesangial proliferation and matrix expansion (3). To date, only
IgM, IgG, and C3 deposits within the mesangium have been
detected, and immunoglobulin A (IgA) nephropathy associated
with falciparum malaria has not yet been reported. Herein, we
present a case of falciparum malaria-associated IgA nephropa-
thy accompanied by AKI that was resolved after recovery from
the malaria infection.

CASE DESCRIPTION
A 49-yr-old Korean male visited our hospital on February 22,
2010 because of persistent fever for three days despite repeated
use of antipyretics. The patient had a 6-yr history of diabetes
and had been receiving treatment at our hospital. Clinical eval-
uations performed 2 months earlier showed serum creatinine
level of 0.9 mg/dL [corresponding to estimated glomerular fil-
tration rate (eGFR) of 95.3 mL/min/1.73m2, calculated using
the 4-variable Modification of Diet in Renal Disease (MDRD)
Study equation] and random urine albumin-creatinine ratio
(ACR) of 42.5 mg/g without microhematuria. Serial urine anal-
yses since the first visit to the clinic consistently showed no mi-
croscopic hematuria. Ophthalmologic evaluation revealed mild
non-proliferative diabetic retinopathy. Two weeks before the
illness, he traveled Uganda in East Africa.
Upon admission, the patient was dehydrated and lethargic.
Blood pressure, pulse rate and body temperature were 110/60
mmHg, 98 beats/min and 38.3°C, respectively. Initial laboratory
tests showed the following values: hemoglobin, 9.0 g/dL; plate-
lets, 57 × 103/µL; serum creatinine, 1.8 mg/dL; aspartate/ala-
nine aminotransferase, 101/90 U/L; total bilirubin, 6.0 mg/dL;
prothrombin time international normalized ratio, 1.03. The pa-
tient tested negative for hepatitis B surface antigen, and anti-
hepatitis C virus antibody. Urine dipstick examination showed
microhematuria (2+) and proteinuria (2+). Spot urine protein-
creatinine ratio (UPCR) and ACR were 2.92 g/g and 1,064 mg/g,
respectively, and 24-hr urinary protein and creatinine excretion

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Yoo DE, et al. • IgA Nephropathy Associated with P. falciparum
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http://dx.doi.org/10.3346/jkms.2012.27.4.446
was 953 and 1,158 mg/day, respectively, with mixed glomerular
and tubular proteinuria on urine electrophoresis. Serum IgA
was elevated to 606 mg/dL, but other serologic tests for antinu-
clear antibody and antineutrophil cytoplasmic antibodies were
negative. C3 and C4 were 95 and 32 mg/dL, respectively.
Based on his travel history and clinical features, malaria was
suspected, and a peripheral blood smear revealed 6% hyperpar-
asitemia with Plasmodium falciparum. The patient was immedi-
ately prescribed intravenous quinine dihydrochloride with oral
doxycycline on the second day of admission. However, he be-
came anuric with increase in serum creatinine up to 4.7 mg/dL
on the third day of admission, and was started on hemodialysis.
To further ascertain the cause of AKI and proteinuria, a kid-
ney biopsy was performed on the 14th day after admission. On
light microscopy, 11 glomeruli showed mild mesangial prolifer-
ation and expansion. In addition, some tubular lumens were
packed with hemosiderin casts, and the interstitium was infil-
trated with many inflammatory cells. Seven glomeruli processed
for immunofluorescence analysis showed mesangial staining
for IgA (1+ to 2+) and C3 (1+). In addition, 3 glomeruli examined
by electron microscopy showed multifocal electron-dense de-
posits within the mesangium and thickened glomerular base-
ment membrane ranging from 800 nm to 1,200 nm in thickness
(Fig. 1).
The patient underwent hemodialysis until the 25th day after
admission. In the meantime, he became negative for P. falci-
parum and his kidney function recovered with increased urine
output. Serum creatinine and UPCR decreased to 2.2 mg/dL
and 0.47 mg/g on the 33rd day after admission, and the patient
was discharged in good condition. Two months later, his serum
creatinine level had decreased to 1.2 mg/dL with UPCR of 0.07
mg/g. Three consecutive urinalyses revealed no microhematu-
ria (Fig. 2). Serum IgA was also normalized to 301 mg/dL.
DISCUSSION
IgA nephropathy is the most common primary glomerulone-
phritis worldwide. It is characterized by mesangial cell prolifer-
Fig. 1. Pathologic findings in a patient with P. falcifarum-associated immunoglobulin A (IgA) nephropathy. (A) The renal biopsy specimen showed mild mesangial proliferation
and expansion (original magnification × 400). (B) Acute and chronic inflammatory cell infiltration in the tubulointerstitium with multifocal hemosiderin casts (original magnifica-
tion × 200). (C) Direct immunofluorescence showed mesangial staining for IgA (2+). (D) Electron microscopy showed multifocal electron-dense deposits within the mesangium
and irregularly thickened glomerular basement membrane ranging from 800 nm to 1,200 nm in thickness. Diffusely effaced foot processes were also observed.
A
C
B
D

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Yoo DE, et al. • IgA Nephropathy Associated with P. falciparum
448 http://jkms.org
http://dx.doi.org/10.3346/jkms.2012.27.4.446
ation, expansion of the extracellular matrix, and predominant
IgA deposition within the mesangium (4). Although the etiolo-
gy of the disease has not been clearly elucidated, some infec-
tious organisms have been reported to be associated with IgA
nephropathy. These include Haemophilus parainfluenzae,
Staphylococcus species, Mycoplasma pneumoniae, and the
Hepatitis B and Dengue viruses, but no individual bacterial or
viral organism has been specifically associated with the devel-
opment of IgA nephropathy (5-9). Meanwhile, in an previous
experimental study, mesangial IgA deposits were rarely noted
in mouse malaria nephropathy caused by Plasmodium berghei
(10). However, similar findings were not reported among hu-
man malaria nephropathy to date. To our best knowledge, this
is the first case suggesting a possible link between IgA nephrop-
athy and Plasmodium falciparum infection.
In line with the previous studies, AKI due to ATN and inter-
stitial nephritis was clearly evident, which clearly explains our
patient’s clinical features. Notably, IgA nephropathy developed
after Plasmodium falciparum infection. One might question
whether the patient had glomerulonephritis or latent IgA ne-
phropathy before the infection. However, the patient had been
followed for 6 yr at our clinic for diabetes management, and
previous blood and urine tests consistently had revealed no evi-
dence of glomerulopathy. In addition, his urine analysis from
2 months before the illness showed no microscopic hematuria
but only microalbuminuria suggesting that glomerulonephritis
such as IgA nephropathy was less likely. Presumably, microal-
buminuria at that time could have been attributed to underly-
ing diabetic nephropathy. In fact, he might have diabetic ne-
phropathy, as evidenced by the biopsy finding showing a thick-
ened glomerular basement membrane and history of coexist-
ing mild non-proliferative diabetic retinopathy. Moreover, sub-
sequent blood and urine tests after recovery from malaria showed
a disappearance of urine abnormalities along with normaliza-
tion of both kidney function and serum IgA level. These find-
ings taken together suggest that Plasmodium falciparum may
have been associated with IgA nephropathy in this patient.
It is uncertain how malaria infection is involved in the devel-
opment of IgA nephropathy. In general, undergalactosylated
IgA1 is reported to play a role in the pathogenesis of idiopathic
IgA nephropathy (11). Such aberrantly glycosylated polymeric
IgA1 are prone to form circulating immune complexes, leading
to mesangial deposition and proliferation (12, 13). The underly-
ing mechanism responsible for this IgA1 abnormality is poorly
understood. However, it is possible that anti-α-galactosyl (anti-
Gal) antibodies may contribute to the development of immune
complexes with aberrantly glycosylated IgA1. Anti-Gal antibod-
ies are originally natural human polyclonal antibodies that spe-
cifically bind to the mammalian carbohydrate structure Galα1,
3Galβ1,4GlcNAc-R (α-galactosyl epitope) on glycoproteins and
glycolipids (14). Some investigators showed that anti-Gal was
associated with IgA nephropathy and Henoch-Schonlein pur-
pura (15). Interestingly, the titers of these antibodies were also
found to be elevated in many of the sera collected from subjects
living in malaria endemic areas or patients with falciparum
malaria (16). It was reported that terminal α-linked galactosyl
residues in some of the carbohydrate side chains of glycopro-
teins of the asexual blood stages of Plasmodium falciparum
could provoke increased anti-Gal production (17, 18). There-
fore, in the present case, it can be surmised that Plasmodium
falciparum might have induced augmented production of anti-
Gal, and in turn, might have caused formation of aberrantly
glycosylated polymeric IgA1. Unfortunately, we could not per-
form any pertinent study to confirm the presence of abnormal
IgA1 because the patient’s serum was not available by the time
the biopsy revealed IgA nephropathy.
Another possible explanation for IgA nephropathy in our re-
port is that clearance of IgA and immune complexes were re-
duced due to liver and/or renal dysfunction. However, such as-
sumptions cannot fully explain why IgA deposits were more
prominent than other immune-complexes within the mesangi-
um in our patient because only IgG, IgM, and C3 deposits have
been reported in malarial nephropathies to date although most
reported cases involved both renal failure and hepatitis.
As in some previous reports on IgA nephropathy associated
with infection (9, 19), the glomerulopathy in our patient ap-
peared to be transient. It is possible that removal of the caus-
ative organism from circulation and improvements in renal and
hepatic dysfunction might result in increased clearance of im-
mune-complexes, thus leading to the resolution of IgA nephrop-
athy. Unfortunately, a second biopsy to prove the complete res-
olution of IgA nephropathy was not feasible because the patient
did not agree to a repeated test. However, based on the results
from consecutive blood and urine tests after recovery from ma-
laria infection, it is likely that such glomerulopathy was resolved.
In addition, although it is not easy to discriminate between true
Serum creatinie, mg/dL
Urine protein-creatinine ratio (mg/g)
-3 y -6 m -2 m
-
-
0 3 d 1 m 2 m 4 m 6 m 8 m
3+1+
3+-
5
4
3
2
1
0
3.3
3
2.7
2.4
2.1
1.8
1.5
1.2
0.9
0.6
0.3
0
Serum creatinine
Urine PCR
Protein
RBC
-
-
-
-
2+
2+
-
-
-
-
-
-
Fig. 2. Changes in kidney function and urine findings during the course of disease. d;
day, m; month, y; year, PCR; protein-creatine ratio.

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http://dx.doi.org/10.3346/jkms.2012.27.4.446
IgAN and IgA-dominant postinfectious glomerulonephritis, the
latter was less likely because hypocomplementemia, diffuse
glomerular endocapillary hypercellularity, and subepithelial
humps (20) were not found in our case (Fig. 1).
In conclusion, our findings suggest that Plasmodium falci-
parum may be involved in the development of IgA nephropathy.
However, this report is limited to a single case and the mecha-
nism responsible for this remains speculative. Further investiga-
tion to elucidate the underlying pathogenesis is required.
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