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CASE PRESENTATION A 52-year-old African woman, living in France since 5 years, presented with dyspnea and pyrexia. She had a 1-month history of sore throat treated with amoxicillin, migratory polyarthralgia, drenching night sweats, and an evanescent, maculo-papular, non-pruritic rash mainly on her limbs lasting less than 1 week at a time. She denied smoking, alcohol abuse, and illicit drugs use. She had no risk factors for HIV. Examination on admission revealed a temperature of 39.51C, tachycardia, a blood pressure of 120/70 mm Hg, pallor, jaundice, splenomegaly, and bilateral inflammation of knee and ankle joints with synovitis, and severe tenderness of the wrist with signs of fluid overload. There was no sign of meningeal irritation, no focal neurological deficit and normal fundus examination. There were fine crepitations involving the left lung base. Heart sounds were normal on auscultation with no murmur. She was admitted for analgesia and antibiotics pending the results of infective screens and blood tests. Peripheral smear showed no malarial parasite. Her coagulation profile was normal and there was no biochemical evidence of hemolysis. Biochemistry values are summarized in Table 1. Human Immunodeficiency Virus serology, plasma HIV viral load, and p24 determination were negative. Serologies for, hepatitis B and C, Parvovirus B19, cytomegalovirus, Epstein–Barr virus, leptospira, bartonella, rickettsia, chlamydia

To the Editor: We acknowledge Zhang et al. for their outstanding review of the new magnetic resonance imaging (MRI) methods in nephrology.1 The authors have described the application of MRI techniques for renal functional imaging in various clinical settings very thoroughly. In prolongation to this excellent review, we would like to share our experience with diffusion-weighted (DW) MRI in assessing renal morphological alterations in two recent cases of immunoglobulin (Ig)G4-related disease. The first was a 65-year-old man who presented with chronic kidney disease. Kidney biopsy showed IgG4-related tubulointerstitial nephritis (TIN). Retrospective analysis of earlier DW MRI images demonstrated bilateral hypointense renal nodules corresponding to water movement restriction.2 The second case was a 47-year-old man referred to the nephrologist because DW MRI (Figure 1a) had shown renal nodules, although renal function was normal.3 Kidney biopsy of nodules detected by DW MRI showed acute IgG4-related TIN with massive inflammatory cell infiltration (Figure 1b), which explained the images of water movement restriction. Our cases illustrate that DW MRI can detect renal morphological alterations in IgG4-related TIN early, thus helping to guide renal biopsy. We agree with the authors that a multidisciplinary approach in the application of this new technique in nephrology clinics should be encouraged for the accurate interpretation of MRI findings and for its correlation with renal physiopathology.

A 72-year-old man was admitted with acute kidney failure. His previous medical history included clear-cell renal cell carcinoma of the right kidney treated with an enlarged nephrectomy 1 year ago. An adenocarcinoma of the right colon had been recently diagnosed and treated with a right colectomy and chemotherapy (folinic acid, fluorouracil, and oxaliplatin: cumulative dose 85 mg/m2). Anuria had developed over the previous 3 weeks. Renal ultrasound ruled out obstruction of the left urinary tract, and a Doppler excluded vascular thrombosis. Hemodialysis was started, and a transjugular renal biopsy was performed to determine the cause of kidney injury (Figure 1). Several lymphatic capillaries were dilated by clusters of atypical cells with a high nuclear/cytoplasm ratio, coarse chromatin, and prominent nucleoli. Immunochemistry revealed a nuclear expression of CDX2, a marker for colonic carcinoma (Figure 2). An 18F-fluorodeoxyglucose positron emission tomography/computed tomography examination confirmed the diagnosis of massive, hypermetabolic, carcinomatous lymphangitis in both lungs and kidney. As far as we are aware, this is the first report of a carcinomatous lymphangitis of non-renal origin spreading into the kidney. Whether the carcinomatous lymphangitis per se caused the kidney failure here is uncertain.