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Chronic Nephritisin a Newborn Infant

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Chronic Nephritisin a Newborn Infant Arch Dis Child: first published as 10.1136/adc.30.152.366 on 1 August 1955. Downloaded from CHRONIC NEPHRITIS IN A NEWBORN INFANT BY ALBERT E. CLAIREAUX and MORTON G. PEARSON From the Bernhard Baron Memorial Research Laboratories, Queen Charlotte's Hospital, and the Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London (RECEIVED FOR PUBUCATION MARCH 3, 1955) Renal disease other than that associated with healthy female child as a result of her second pregnancy congenital malformations is rare in the newborn in 1951. infant. Formerly syphilis played an important role During the pregnancy she seemed quite well until the renal disease in beginning of the third month when she had a mild throat in the production of inflammatory infection. A more severe throat infection occurred infants, but with modern methods of ante-natal care during the fifth month. Similar attacks had occurred congenital syphilitic nephritis is almost unknown in during the previous two years. She was first seen during this country. the seventh week of her pregnancy. Blood pressure was Glomerular changes, consisting mainly of hya- 115 70 mm. Hg and her urine contained no abnormal linization and fibrosis of the glomerular tufts, were constituents. Wassermann and Kahn reactions were described by Herxheimer (1909) and by Schwarz negative. Her haemioglobin was 13 -5 g. 00 and she was (1928). These lesions were called 'congenital Group 0 Rh positive. No abnormality was seen in a glomerulosclerosis by Friedman, Grayzel and radiograph of the chest. The patient thereafter attended her local county council ante-natal clinic until the 36th Lederer (1942) who reviewed the subject in some week when she was again seen at hospital. No abnor- detail. More recently Swan (1944) and Tedeschi, mality was found at this examination. by copyright. Halpern and Ingalls (1953) have reported similar Labour began spontaneously on August 9, 1954, lesions in the kidneys of infants whose mothers had 19 days before the estimated date of delivery. On suffered from rubella during pregnancy. It is felt, admission to hospital a breech presentation of the foetus however, that these changes are probably vascular was diagnosed. The membranes were still intact but the rather than infective in origin and are not specific foetal heart was irregular. Breech delivery was effected manifestations of infection by rubella virus. two hours later. The placenta weighed 794 g. The is as un- puerperium was uneventful. On November 15, 1954, True glomerulonephritis regarded being her throat was clear. A swab yielded no pathogens. common by Zuelzer, Charles, Kurnitz, Newton and The anti-streptolysin titre of the blood was 200 units mnl. Fallon (1951) and according to Potter (1952) is Blood urea was 22 mg. 100 ml. and uric acid 1-7 mg. http://adc.bmj.com/ unknown in the newborn infant. 100 ml. The patient was a male infant of 6 lb. 13 oz. Recently, however, there have been three reports (3,091 g.) birth weight. He was apnoeic at birth, had of glomerulonephritis occurnng in newborn infants a feeble cry and took infrequent gasps. He improved (Thompson, 1951; Collins, 1954; Kunstadter and after assisted breathing in a servo-respirator but in- Rosenblum, 1954). These authors regarded the drawing of the chest persisted. Crepitations were condition as an extreme rarity and were unable to present in both lung fields. On radiological examination, find reports of similar cases in the literature. bilateral pneumothorax was found. The infant died aged 10 hours. on September 23, 2021 by guest. Protected Lapage (1932) had described a case of acute haemor- rhagic nephritis in the newborn, but glomerular Necropsy. The body was that of a well developed changes were absent. male infant weighing 3,175 g. No congenital abnor- In this paper we describe a case of nephritis in a mality was found on external examination. The ten- newborn infant. The renal changes were most torium was tom on both sides and there was severe severe and affected the glomeruli, tubules and inter- bilateral subdural haemorrhage. The brain was normal. stitium. The larynx, trachea and bronchi were healthy. There was a pneumothorax on the left side. The lungs were Case Report congested and poorly expanded. The right lung was The mother was a healthy woman of 29 years of age, atelectatic and sank in water. The left lung floated as a and this was her third pregancy. Her first pregnancy result of gross emphysema. Large emphysematous in 1948 resulted in the birth of a female child who bullae were present in the interlobular fissures. subsequently showed pyloric stenosis. She had a The heart and great vessels were normal. 366 Arch Dis Child: first published as 10.1136/adc.30.152.366 on 1 August 1955. Downloaded from CHRONIC NEPHRITIS IN A NEWBORN INFANT 367 A few petechial haemorrhages were present in the small crescent formation and in some cases the capsular space intestine. The liver and pancreas were healthy. had been obliterated by this process (Fig. 2). Pseudo- The kidneys were quite large (each weighed 26 g.). crescent formation was also observed in a number of Their appearance was similar. They showed foetal instances (Fig. 3). Here the glomeruli showed partial lobulation and the capsule stripped easily. Their surface hyalinization and a neighbouring convoluted tubule was was generally smooth, but a few minute cysts, 0 5-1 mm. becoming adherent to the glomerular capsule. The diameter, were present. The cysts had smooth walls latter showed epithelial proliferation and eventually and contained a little fluid. Nuumerous petechiae were the complex would have become hyalinized and sur- present over the surface of the kidneys. On slicing the rounded by fibrous tissue. The end-result would there- cortex and medulla could be easily differentiated. The fore be almost indistinguishable from the crescent cortex was congested and numerous silvery streaks were described above (Fig. 2). In other glomeruli capsular seen running at right angles to the surface. Occasional proliferation was less pronounced, but some adhesions small cysts were seen. The pyramids showed a few were present between the glomerular tufts and the small haemorrhages. The calyces and pelvis were capsule. In a few instances the capsular space contained healthy. The renal vessels appeared normal and the acidophile material with an occasional polymorpho- ureters and bladder were healthy. nuclear leucocyte. Glomeruli undergoing atrophy were The spleen appeared normal. The suprarenal glands, present throughout the cortex, but those exhibiting thymus, thyroid and pituitary glands were healthy. proliferative change were more frequently found near the cortico-medullary junction. Histology. The left lung showed numerous sub- The tubular changes were even more striking. The pleural emphysematous bullae. Patchy intra-alveolar small superficial cortical cysts seen on macroscopic haemorrhage was seen in both lungs. The right lung examination proved to be grossly dilated tubules con- was unexpanded. There was no pneumonia. taining acidophile fluid. About half the cortical tubules The liver and spleen showed no abnormality. were dilated and contained colloid casts (Fig. 1). This The capsule of the kidneys showed little change. The gave the kidney a thyroid-like appearance. The dilated glomeruli were reduced to about one-third of their tubules were lined by flattened atrophic epithelium. usual number. Of the remainder, few were completely The convoluted tubules were more affected than the normal. Many were atrophic and showed periglomeru- collecting tubules but the latter also showed cyst for- lar concentric fibrosis (Fig. 1). A few showed prolifera- mation. A few convoluted tubules showed true hyper- by copyright. tion of the cells of Bowman's capsule with striking trophy and their epithelium was thrown into papilliform http://adc.bmj.com/ on September 23, 2021 by guest. Protected AEM L; -J 4 FK;. I.-Renal cortex showing glomerular atrophy, tubular dilatation FIG. 2.-Glomerulus showing partial hyalinization of the tuft and and colloid casts in the convoluted tubules. Large haemopoietic epithelial cell proliferation of the capsule with crescent formation. foci are present on the left. Haernatoxylin and ersin x 75. Haematoxylin and eosin x 375. Arch Dis Child: first published as 10.1136/adc.30.152.366 on 1 August 1955. Downloaded from 368 ARCHIVES OF DISEASE IN CHILDHOOD folds. In addition to the acidophile colloid material of pus in a number of tubules, the increase in the a number of tubules contained polymorphonuclear interstitial connective tissue which showed infiltra- leucocytes and cellular debris. Only very few tubules, tion with polymorphonuclear leucocytes and the however, contained purulent material and the majority glomerular atrophy with concentric pericapsular contained no cells at all. A few tubules showed erosion fibrosis all point to this diagnosis. We feel that of their walls by an inflammatory process and numerous leucocytes were present. only a few glomeruli showed truly proliferative In addition to cystic dilatation a number of convoluted lesions and these were insufficient to account for tubules showed pronounced hyaline droplet degeneration the gross alteration of the cortical architecture. The of their lining cells (Fig. 4). Their cells were pale and glomerular changes were probably the result of an swollen and in places the epithelium was replaced by 'alterative glomerulitis'. This change has been bright acidophile droplets. A number of convoluted described in pyelonephritis by Kimnmelstiel and tubules showed severe hyaline change and their epi- Wilson (1936). These authors have shown that in thelium was converted into a hyaline band (Fig. 5). In some cases of pyelonephritis there is hyalinization some cases two or more such hyalinized tubules had of some loops of the glomerular tuft with the fused. No cytoplasmic inclusion bodies were seen and no organisms were found in sections stained by Gram's formation of capsular adhesions. Occasionally this method. is followed by capsular proliferation. They also The interstitial tissue also showed marked alteration.
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