A 15-Year-Old Girl with an Unusual Cause of Intermittent Gross Hematuria

Sep 30, 2026

A 15-year-old girl experienced intermittent gross hematuria with diarrhea, abdominal pain, and intermittent hand arthralgia after viral and bacterial infections. Workup showed Shiga-toxin Escherichia coli infection complicated by acute kidney injury and hematuria. Urinalysis demonstrated dysmorphic RBCs and a RBC cast; biopsy revealed diffuse endocapillary hypercellularity by monocytes with negative conventional and pronase-based immunofluorescence but rare deposits on ultrastructure. Cryoglobulin testing confirmed type 3 cryoglobulinemia, and she was treated with steroids and rituximab, preserving kidney function 16 months later.

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A 15-Year-Old Girl with an Unusual Cause of Intermittent Gross Hematuria Natasha Freeman , 1 Namrata G. Jain,2 and Satoru Kudose 3 Kidney360 6: 1828–1829, 2025. doi: [https://doi.org/10.34067/KID.0000000875](https://doi.org/10.34067/KID.0000000875) Case Presentation A 15-year-old girl with a history of intermittent gross hematuria (three episodes over the course of 8 months) associated with viral and bacterial infection presented with diarrhea, abdominal pain, and intermittent arthralgia in her hands. She was found to have a Shiga-toxin Escherichia coli infection complicated by AKI and gross hematuria. Serum creatinine was 1.31 mg/dl with normal electrolytes, urine protein 0.2 g/g creatinine, hemoglobin of 10.0 g/L, platelet count 2153103 /ml, haptoglobin 125 mg/dl, and lactate dehydrogenase 245 U/L. Urinalysis showed 31 protein, large blood, 11–20 white blood cells and .50 red blood cells (RBCs) per high powered ﬁeld with dysmorphic RBCs and a RBC cast. Serological workup revealed positive anti-nuclear antibody (titer 1:80), negative/ normal complement levels C3 and C4, anti–double-stranded DNA antibody, anti-neutrophilic cytoplasmic antibodies, anti-streptolysin O antibody, and hepatitis B and C. Genetic testing (Natera Renasight) did not reveal pathogenic mutations. Kidney biopsy (Figure 1) revealed diffuse endocapillary hypercellularity by monocytes (Figure 1), with negative conventional immunoﬂuorescence and immunoﬂuorescence on pronase-digested parafﬁn-embedded tissue. Ultrastructural evaluation revealed rare mesangial and subendothelial deposits (Figure 2) . Although the lack of immunoreactivity makes deﬁnitive classiﬁcation difﬁcult,(1) endocapillary hypercellularity by monocytes and (2) discordance between the degree of hypercellularity and amount of deposits were suspicious for cryoglobulinemic GN (cryoGN) . Such discordance likely reﬂects aggressive clearance by monocytes and is atypical for more common glomerulonephritides in children, such as IgA nephropathy. Subsequently, serum cryoglobulin testing revealed acryocrit of 1%, classiﬁed as type 3 cryoglobulinemia by immunoﬁxation. Rheumatologic and infectious workups were negative. The patient was diagnosed with idiopathic Figure 1. Kidney biopsy revealed glomeruli with diffuse segmentalto global endocapillary hypercellullarity by mononuclear leukocytes and a few neutrophils. The glomerular basement membranes showed rare segmental duplication. No signiﬁcant mesangial hypercellularity, ﬁbrin or immune thrombi, or crescents were seen. Mild tubulointerstitial scarring, minimal arteriosclerosis and arteriolosclerosis were present. Both conventional IF and IF performed on pronase-digested parafﬁn-embedded tissue was negative for all reactants (not shown) . Original magniﬁcation 6003, periodic acid–Schiff stain. IF, immunoﬂuorescence. type 3 cryoglobulinemia and was treated with steroids andrituximab (weekly 34 at 375 mg/m2, then maintenance every 6 months), a regimen which has proven effective for mixed cryoGN in the adult literature.1 Sixteen months following biopsy, she remains with preserved kidney function. Discussion Cryoglobulins are immunoglobulins (Ig) that precipitate at ,37°C and then redissolve at .37°C. Type 1 1Division of Nephrology, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York 2Division of Pediatric Nephrology, Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center, Hackensack, New Jersey 3Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York Correspondence: Dr. Satoru Kudose, email: [sk4521@cumc.columbia.edu](sk4521@cumc.columbia.edu) Copyright © 2025 The Author(s) . Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Nephrology. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where

FAQs

What symptoms and preceding infection were associated with the patient’s intermittent gross hematuria?

The patient had three episodes of intermittent gross hematuria over eight months, associated with viral and bacterial infection, along with diarrhea, abdominal pain, and intermittent arthralgia of the hands. Shiga-toxin Escherichia coli infection was identified and complicated by acute kidney injury.

What did the kidney biopsy and immunofluorescence show?

Biopsy showed diffuse endocapillary hypercellularity by monocytes, with rare mesangial and subendothelial deposits on ultrastructure. Conventional immunofluorescence and immunofluorescence on pronase-digested paraffin-embedded tissue were negative, making definitive classification difficult.

How was the underlying diagnosis confirmed and what treatment was used?

Serum cryoglobulin testing showed an acryocrit of 1%, classifying type 3 cryoglobulinemia by immunofixation, with negative rheumatologic and infectious workups. Treatment with steroids and rituximab led to preserved kidney function 16 months after biopsy.

Sep 30, 2026

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