Rheumatology Case Report: TINU Syndrome with Concomitant Synovitis

Tubulointerstitial nephritis and uveitis syndrome is a rare oculo-renal inflammatory disease.
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Tubulointerstitial nephritis and uveitis (TINU) syndrome, also known as Dobrin syndrome, is a rare oculo-renal inflammatory disease. It was first described in 1975 by American physician Robert Dobrin, MD.¹ It manifests as acute interstitial nephritis and bilateral uveitis. In addition, patients often experience nonspecific systemic findings, such as fever, weight loss, malaise, myalgia and arthralgia.

TINU syndrome has an excellent prognosis. It has been sporadically documented in case reports in various ophthalmology and nephrology journals. It mostly occurs in adolescents and young females, with a median age of onset of 15 years.² Much of the underlying pathophysiology remains unclear; however, T lymphocytes have been reported to play a significant role in this syndrome.³ Certain associations have been documented, but in most cases, no risk factors are identifiable.⁴

We report a case of TINU syndrome in which the patient initially presented with hand synovitis before the development of oculo-renal disease.

Case Report

A 29-year-old Caucasian woman with a past medical history of iron-deficiency anemia presented to our rheumatology clinic in November 2016 for evaluation of bilateral hand pain and swelling of one-year duration, associated with one hour of morning stiffness.

Six months before, she had been treated with antibiotic eyedrops for an eye infection. The infection cleared up, but she soon developed bilateral uveitis and was treated with steroid eyedrops (prednisolone acetate 1%). The steroid eyedrops were gradually tapered off, but her uveitis soon recurred.

She presented to a new ophthalmologist and was found to have bilateral, non-granulomatous anterior uveitis. Her topical steroid frequency was increased to six times daily, but she continued to have low-grade uveitis. She was switched to a higher potency steroid drop (difluprednate 0.05%), with a good response.

A uveitis workup was recommended by her ophthalmologist. The differential diagnoses included post-infectious uveitis, sarcoidosis, Behçet’s, TINU syndrome, Lyme disease and HLA-B27-associated uveitis.

On physical exam, the patient was unable to make a fist and had clinical evidence of bilateral synovitis of her second and third proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints.

Urinalysis demonstrated 11–30 WBC/hpf, 11–30 RBC/hpf and elevated urine beta-2 micoglobulin at 1140 µg/L (reference range: 0–300 µg/L). Urine cultures were negative for growth. The rest of her laboratory test results were unremarkable, other than mildly elevated CRP, as shown in Table 1. A chest X-ray was normal.