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FIGURE 9-11 (see Color Plate)

FIGURE 9-10 (see Color Plate)

Interstitial nephritis with edema and a mononuclear inflammatory infiltrate. Eosinophils in the infiltrate suggest a possible hypersensi-tivity reaction (hematoxylin and eosin, original magnification X400). Drugs are the most common cause of such a reaction, which often presents with acute renal failure [6]. Inflammatory cells and cell casts may be seen in the urine sediment in these cases, as inflammatory cells infiltrate the tubular epithelium.

FIGURE 9-11 (see Color Plate)

Tubulitis, with infiltration of mononuclear cells into the tubular epithelium (hematoxylin and eosin, original magnification X 400). There is a mononuclear infiltrate and edema in the surrounding interstitium. Tubule cells may show evidence of lethal or sublethal injury as the inflammatory cells release damaging enzymes. Tubulitis is often seen in interstitial nephritis especially if the targets of the inflammatory reaction are tubular cell antigens or antigens deposited around the tubules. Immunofluorescence may reveal granular or linear deposits of immunoglobulin and complement around the tubules.

FIGURE 9-13 (see Color Plate)


FIGURE 9-13 (see Color Plate)

Fine-needle aspirate of acute infectious interstitial nephritis (acute pyelonephritis). A 25-gauge needle attached to a 10-cc syringe was utilized to withdraw the aspirate into 4 cc of RPMI-based medium. The specimen was then cytocentrifuged and stained with May-Grunwald Giemsa. A, The renal aspirate contains large numbers of intrarenal neutrophils, which are focally undergoing degenerative changes with cytoplasmic vacuolization and nuclear

FIGURE 9-12 (see Color Plate)

Polymorphonuclear leukocytes forming a cast in a cortical tubule (hematoxylin and eosin, original magnification X 400). Note edema and inflammation in adjacent interstitium. These intratubular cells are highly suggestive of acute infection, and may be seen in distal as well as proximal nephron as part of an ascending infection. Intra-tubular PML may also be seen in vasculitis and other necrotizing glomerular processes, in which these cells escape across damaged areas of the inflamed glomerular tuft.

breakdown. In bacterial infection there are many infiltrating neu-trophils and there may be associated necrosis of tubule epithelial cells (original magnification X 80). B, A neutrophil contains phagocytosed bacteria within the cytoplasm; bacteria stain with Giemsa, so are readily detectable in this setting. Adjacent tubule epithelial cells have cytoplasmic granules but do not phagocytize bacteria (original magnification X 160).

FIGURE 9-14 (see Color Plate)

Numerous polymorphonuclear leukocytes (PML) in the urine sediment of a patient with acute pyelonephritis (hematoxylin and eosin, original magnification X 400). Some red blood cells and tubular cells are seen in the background of this cytospin preparation. PML may be found in the urine with acute infection of the lower urinary tract as well, or as a contaminant from vaginal secretions in females. PML casts, on the other hand, are evidence that the cells are from the kidney.

FIGURE 9-14 (see Color Plate)

FIGURE 9-15 (see Color Plate)

Fine-needle aspirate from patient with intrarenal cytomegalovirus (CMV) infection. A, There are activated and transformed lymphocytes with immature nuclear chromatin and abundant blue cytoplasm that infiltrate the kidney in response to the infection; large granular lymphocytes (NK cells) may be seen as well, but few neutrophils. Similar activated lymphocytes, NK cells, and atypical monocytes can be observed within the peripheral blood. The tubule epithelial cells are virtually never seen to contain CMV inclusions in aspirate material, in contrast to core biopsy specimens. All intrarenal viral infections have a similar appearance, and immunostaining or in situ hybridization is required to identify specific viruses (May-Grunwald Giemsa, original magnification X 80). B, Tubular epithelial cells stained with antibody to CMV immediate and early nuclear proteins in active intrarenal CMV infection. With an immunoalka-line phosphatase method, cytoplasmic and prominent nuclear staining for these early proteins are observed in the tubular epithelium. In very early infection, neutrophils also may have cytoplasmic staining for these proteins (original magnification X 240).

FIGURE 9-16 (see Color Plate)

Numerous eosinophils in an interstitial inflammatory infiltrate. Eosinophils may be diffuse within the infiltrate, but may also be clustered, forming "eosinophilic abscesses," as in this area (hematoxylin and eosin, original magnification X 400). Eosinophils may also be demonstrated in the urine sediment. Drugs most commonly producing acute interstitial nephritis as part of a hypersensitivity reaction include: penicillins, sulfonamides, and nonsteroidal antiinflammatory drugs [6]. The patient had recently undergone a course of therapy with methicillin. The interstitial nephritis may be part of a systemic reaction which includes fever, rash, and eosinophilia.

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FIGURE 9-17 (see Color Plate)

FIGURE 9-17 (see Color Plate)

Fine-needle aspirate of acute allergic interstitial nephritis. A, The aspirate contains numerous lymphocytes, occasional activated lymphocytes, and eosinophils without fully transformed lymphocytes, corresponding to the inflammatory component within the tubuloint-erstitium observed on routine renal biopsy. Monocytes often are present (May-Grunwald Giemsa, original magnification X 80). B, Higher magnification showing the typical infiltrating cells, including a monocyte, activated lymphocyte, and an eosinophil. A neutrophil is present, likely owing to blood contamination (May-Grunwald Giemsa, original magnification X 160).

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