Henoch-Schönlein purpura in a patient with diabetic nephropathy

A 46-year-old man presented with Henoch-Schönlein purpura and diabetic nephropathy. At 30 years of age, the patient had presented with an acute and severe nephritic syndrome with severe renal impairment. The renal function returned to normal 6 months after this first attack. At the age of 38 years, the patient was diagnosed as having type II diabetes and was treated with diet alone. At 44 years of age, a renal biopsy was performed because of proteinuria and hematuria. In this renal biopsy, mesangial expansion, medial arterial hyperplasia, and focal interstitial fibrosis were found to be present. Mesangial and subendothelial deposits of immunoglobulin A (IgA) were demonstrated by immunofluorescence. At 45 years of age, cutaneous vasculitis appeared, and at 47 years of age, the patient presented with necrotic purpura, non-insulin-dependent diabetes, renal impairment, proteinuria, and hematuria. A skin biopsy demonstrated leukocytoclastic skin vasculitis with IgA deposits in the arterial walls. A second renal biopsy was performed that showed diabetic glomerulosclerosis associated with a marked vascular and interstitial fibrosis. Mesangial and subendothelial deposits of IgA and C3 and linear IgG deposits along the glomerular basement membranes were demonstrated by immunofluorescence. Electron microscopy showed that the glomerular basement membranes were thickened; a fusion of foot processes was observed and electron-dense deposits were present in the widened mesangium. In summary, we describe a patient with a history of ancient glomerulonephritis who presented with an IgA mesangial nephropathy consistent with Henoch-Schönlein purpura associated with diabetic glomerulosclerosis.