Idiopathic immune complex-mediated tubulointerstitial nephritis with hypocomplementemia and neutrophil-rich interstitial infiltrates

A 69-year-old man presented with acute kidney injury, hypocomplementemia. antinuclear antibody, and anti-dsDNA antibody. He had no signs of systemic lupus eiythematosus or Sjogren syndrome. He had not begun taking any new drugs in the preceding 6 months. Kidney biopsy revealed 13 glomeruli, 3 with global sclerosis. The remaining glomeruli showed slight mesangial proliferation. The interstitial inflammation was extensive, comprising mainly mature lymphocytes and plasma cells, neutrophils, and a few eosinophils. Remarkable granular and diffuse deposition of IgG and C1q was observed along the tubular basement membranes. Electron microscopy showed electron-dense deposits in the tubular basement membrane. Immunohistochemistiy showed only 1 - 4 IgG4-positive plasma cells per high-power field and an IgG4/CD138 ratio of similar to 10%. He was treated with oral prednisolone 35 mg/day, and his kidney function gradually improved. This is a unique case that is not consistent with any known disease entities with immune complex-mediated tubulointerstitial nephritis.