A Diagnostic Challenge—TINU Syndrome

Authors

• Sophia Lee, MD, ProvidenceFollow
• Claire Kassakian, MD, ProvidenceFollow

Files

Publication Date

2025

Keywords

oregon, ppmc, oregon gme

Disciplines

Medical Education | Nephrology | Ophthalmology | Pharmacy and Pharmaceutical Sciences

Abstract

Introduction: •TINU Syndrome: Tubulointerstitial Nephritis and Uveitis  rare multi-system syndrome  has renal manifestations typical of acute interstitial nephritis (AIN), in addition to bilateral anterior uveitis  not well-understood •Thought to be an immune-mediated process, although mechanisms for disease remain unclear  Likely secondary to a combination of genetic predisposition and certain environmental exposures •Genetic predisposition:  specific HLA phenotypes  possibly an auto-antigen to modified C-reactive protein (mCRP) •Potential triggers:  Infections: tuberculosis, EBV, varicella zoster, chlamydia, toxoplasma  Medications: antibiotics (β-lactams, meropenem, azithromycin, levofloxacin), NSAIDs, goreisan (Chinese herb)  Endocrine diseases: hypoparathyroidism, hyperparathyroidism, rheumatoid arthritis, IgG4-related autoimmune disease, thrombotic microangiopathy Discussion & Learning Posts: •This case is an example of an extremely rare condition with potentially devastating outcomes if not caught early enough  visual impairment  dialysis dependence •Treatment for patients with progressive renal dysfunction is usually high-dose prednisone of 1 mg/kg per day (up to 40-60 mg/day)  3-6 month duration of treatment (depending on response)  Long taper •Rarely, some patients are treated with mycophenolate mofetil if no benefit from steroid therapy •Fortunately, kidney disease can be self-limited in many patients, however, patients who have developed TINU syndrome are at risk of relapses •Demonstrates the need for a high clinical suspicion for this combination of symptoms:  a pyuria suspicious for AIN  tubular proteinuria  eye redness and pain •Symptoms often do not correlate temporally!  In fact, the majority of cases present with renal injury preceding uveitis •important to include TINU in the differential  thoroughly assess a review of all systems when taking a history •Also key to note is the risk of future recurrence in patients who have developed TINU syndrome  Need for ongoing monitoring

Area of Special Interest

Kidney & Diabetes

Specialty/Research Institute

Graduate Medical Education

Specialty/Research Institute

Nephrology

Specialty/Research Institute

Ophthalmology