Rheumatology Case Report: TINU Syndrome with Concomitant Synovitis

Although not present in our patient, in some cases of TINU, kidney involvement may present as acute renal failure with proteinuria and glycosuria.⁸

Our case demonstrates an uncommon presentation in which ocular involvement preceded renal disease. A majority of TINU patients develop uveitis after a biopsy-proved diagnosis of tubulointerstitial nephritis.⁴ This case is unique because our patient presented with bilateral symmetrical synovitis of her PIP and DIP joints, which occurred about six months before the onset of ocular symptoms and more than one year before the diagnosis of interstitial nephritis.

Although TINU may be associated with systemic findings, such as fever, weight loss and fatigue, synovitis is not a well-documented finding in this syndrome.⁹ This raises a question regarding whether common autoantigens (known to both the uveal and renal tubular cells) play a role in joint synovial tissue.

We found only one other case report that described the onset of bilateral synovitis, in that case in the knees of a 16-year-old Turkish male with prior diagnosis of TINU.¹⁰

Dr. Chawla

Ambreesh Chawla, MD, is a third-year postgraduate internal medicine resident at Saint Barnabas Medical Center, Livingston, N.J. With a background in biomedical engineering, Dr. Chawla’s primary goal is to complete a rheumatology fellowship and practice rheumatology, with a focus on clinical research.

David Benderson, MD, is an ophthalmologist with Valley Health System in Ridgewood, N.J.

Dr. Kotlov

Mikhail Kotlov, MD, is a nephrologist with Valley Health System in Midland Park, N.J.

Dr. Leibowitz

Evan Leibowitz, MD, is a rheumatologist with Valley Health System in Midland Park, N.J.

Dr. Raslan

Ashraf Raslan, MD, is a rheumatologist with Valley Health System in Midland Park, N.J.

References

1. Dobrin RS, Vernier RL, Fish AL. Acute eosinophilic interstitial nephritis and renal failure with bone marrow-lymph node granulomas and anterior uveitis. A new syndrome. Am J Med. 1975 Sep;59(3):325–333.
2. Sessa A, Meroni M, Battini G, et al. Acute renal failure due to idiopathic tubulo-intestinal nephritis and uveitis: ‘TINU syndrome.’ Case report and review of the literature. J Nephrol. 2000 Sep–Oct;13(5):377–380.
3. Yoshioka K, Takemura T, Kanasaki M, et al. Acute interstitial nephritis and uveitis syndrome: Activated immune cell infiltration in the kidney. Pediatr Nephrol. 1991 Mar;5(2):232–234.
4. Li C, Su T, Chu R, et al. Tubulointerstitial nephritis with uveitis in Chinese adults. Clin J Am Soc Nephrol. 2014 Jan;9(1):21–28.
5. Tan Y, Yu F, Qu Z, et al. Modified C-reactive protein might be a target autoantigen of TINU syndrome. Clin J Am Soc Nephrol. 2011 Jan;6(1):93–100.
6. Cigni A, Soro G, Faedda R, et al. A case of adult-onset tubulointerstitial nephritis and uveitis (‘TINU syndrome’) associated with sacroileitis and Epstein-Barr virus infection with good spontaneous outcome. Am J Kidney Dis. 2003 Sep;42(3):E4–E10.
7. Kase S, Kitaichi N, Namba K, et al. Elevation of serum Krebs von den Lunge-6 levels in patients with tubulointerstitial nephritis and uveitis syndrome. Am J Kidney Dis. 2006 Dec;48(6):935–941.
8. Gallego N, Estepa R, Mampaso F, et al. Tubulointerstitial nephritis and asymptomatic uveitis. J Nephrol. 2000 Sep–Oct;13(5):373–376.
9. Takemura T, Okada M, Hino S, et al. Course and outcome of tubulointerstitial nephritis and uveitis syndrome. Am J Kidney Dis. 1999 Dec;34(6):1016–1021.
10. Öktem F, Tunc S, Olgar S, et al. Tubulointerstitial nephritis and uveitis syndrome with symmetrical synovitis in a male adolescent. Eur J Gen Med. 2005 Jan;2(1):27–31.