Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis

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It may be idiopathic or due to secondary causes. Among the secondary causes, heavy metals like mercury are the one among others. Here is a male with nil comorbidities who, upon exposure to mercury-containing skin cream, developed proteinuria, which, on evaluation, was found to have dual renal lesions like membranous nephropathy and chronic interstitial nephritis. The uniform PLA2R staining within the glomerular capillary walls shows the ability of mercury to induce inflammation and autoimmunity. This case strengthens the findings of in vitro studies about mercury-induced inflammatory processes." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-545", "name": "Case Report: Mercury-induced renal autoimmunity – An insight into..." } } ] } Home Browse Case Report: Mercury-induced renal autoimmunity – An insight into... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article C Shetty B, Yadiyal B M and Bhat M A. Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.12688/f1000research.149755.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] Bhushan C Shetty https://orcid.org/0000-0001-7698-3339 1 , Muralidhara Yadiyal B 2 , Ashok Bhat M 1 Bhushan C Shetty https://orcid.org/0000-0001-7698-3339 1 , Muralidhara Yadiyal B 2 , Ashok Bhat M 1 PUBLISHED 28 May 2024 Author details Author details 1 Nephrology, Kasturba Medical College Mangalore Manipal Academy of Higher Education Manipal India, Karnatak, 575001, India 2 Medicine, Kasturba Medical College Mangalore Manipal Academy of Higher Education Manipal, Karnataka, 575001, India Bhushan C Shetty Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Muralidhara Yadiyal B Roles: Supervision, Validation, Visualization, Writing – Review & Editing Ashok Bhat M Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Manipal Academy of Higher Education gateway. Abstract Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in adults. It may be idiopathic or due to secondary causes. Among the secondary causes, heavy metals like mercury are the one among others. Here is a male with nil comorbidities who, upon exposure to mercury-containing skin cream, developed proteinuria, which, on evaluation, was found to have dual renal lesions like membranous nephropathy and chronic interstitial nephritis. The uniform PLA2R staining within the glomerular capillary walls shows the ability of mercury to induce inflammation and autoimmunity. This case strengthens the findings of in vitro studies about mercury-induced inflammatory processes. READ ALL READ LESS Keywords mercury, membranous nephropathy, chronic interstitial nephritis, proteinuria Corresponding Author(s) Bhushan C Shetty ( [email protected] ) Close Corresponding author: Bhushan C Shetty Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 C Shetty B et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: C Shetty B, Yadiyal B M and Bhat M A. Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.12688/f1000research.149755.1 ) First published: 28 May 2024, 13 :545 ( https://doi.org/10.12688/f1000research.149755.1 ) Latest published: 28 May 2024, 13 :545 ( https://doi.org/10.12688/f1000research.149755.1 ) Introduction Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in adults. They are characterized by basement membrane thickening and minimal or no cellular proliferation with immune deposits on the epithelial side of glomerular capillary walls. 1 The majority are idiopathic, and some can be due to autoimmune diseases, malignancies, and exposure to heavy metals like mercury. Mercury exposure has effects on various organ systems, including the immune system. Here, we would like to report a case with dual renal lesions on histopathology caused by the usage of mercury-containing skin cream. Case A 26-year-old male with nil comorbidities, driver by occupation, presented to our outpatient department with easy fatigability of 2 months duration. He had not been evaluated for the same prior. He was normotensive. Labs ( Table 1 ). Table 1. Laboratory investigations of the patient (HIV – Human Immunodeficiency Virus, HBsAg – Hepatitis B surface antigen, hepatitis C Virus, C3 – Complement 3, ANA – antinuclear antibody). Admission values Reference values Hemoglobin (g/dl) 11.6 13-17 Total leucocyte count (cells/cumm) 8400 4000-10000 Platelets (lakh/mm 3 ) 3.6 1.5-4.5 Urea (mg/dl) 28 Creatinine (mg/dl) 1.7 0.7-1.2 Sodium (mmol/l) 138 135-145 Potassium (mmol/l) 3.9 83.5-5.3 Serum albumin (mg/dl) 3 3.5-4.5 Urine routine Album 2+, pus cells 2-3, RBC nil 24 hour urine protein (mg) 1600 <150 HIV, HBsAg, HCV Nonreactive C3 110 90-130 ANA (IF) Negative Serum protein electrophoresis Normal Peripheral smear Normocytic normochromic He was admitted for renal biopsy and underwent the same. Post biopsy, he was discharged and came back to our OPD (outpatient department) with the biopsy reports almost a month later. Biopsy revealed features suggestive of a moderate degree of chronic interstitial nephritis and membranous glomerulonephritis ( Figures 1 & 2 ). Immunofluorescence revealed glomerular tufts showing FOCAL and SEGMENTAL distributed finely granular deposits with IgG(3+), C3(1+), Kappa(2+), Lambda(2+) along the capillary walls and others were negative. PLA2R(phospholipase A2 receptor) - glomerular capillaries showed diffuse and globally distributed uniform granular staining along the capillary walls. Figure 1. H&E stain severe interstitial inflammation composed of lymphocyte and eosinophils (300 dpi). Figure 2. MAT stain 3 globally sclerosed glomeruli with tubulointersitium showing interstitial fibrosis and tubular atrophy with dense chronic inflammation (300 dpi). Chest radiograph was normal, ultrasound of abdomen revealed normal-sized kidneys, and there was no history of NSAIDS or native medicine intake. On probing his history, he admitted that, due to his dark complexion, he had been using a skin-lightening cream [Beauty Cream] on his face and forearms for the previous eight months given by his friend, but stopped when he had developed symptoms of easy fatigability. The cream was sent for heavy metal analysis, and the mercury content was found to be 9308.6 mg/kg, which is approximately 7,500 times higher than that prescribed by the Minamata convention. We sent his 24-hour urine for mercury levels (though he had stopped using the cream for >3 months) for academic purposes, which was within normal limits. Serum PLA2R levels were not done due to financial constraints. He was treated with ACEi and other supportive care. He is better, and subsequent follow-up urine analysis showed proteinuria regression. Discussion Membranous Nephropathy is associated with a lot of morbidity and mortality, with 20–50% of may have progressive renal disease. 2 When it is associated with another renal lesion, as it happened in our patient, the progression of renal disease will be accelerated. Mercury may damage the kidney in several ways. It may cause tubular or glomerular damage based on whether the exposure is acute or chronic. Acute exposure causes tubular necrosis, and chronic exposure involves the glomerulus 3 ; both the compartments are involved here. If the exposure doesn’t cease, then the tubular necrosis may lead to tubular atrophy and fibrosis, which is evident in the renal histology of our patient. There have been previously published reports of mercury poisoning caused by skin-lightening creams. For example, there were more than 200 cases of women poisoned by mercury after using one kind of skin-lightening cream produced by Mexico in 1995. Mercury poisoning was also reported in about 100 women in Hong Kong after the use of cosmetics made in Mainland China. 4 The diagnosis mainly rests on the temporal association with history, detection of mercury in the sample, and if presented <3 Months, 24-hour urinary mercury levels may give a clue. The peculiarity of our case here is the presence of solid and uniform PLA2R staining along the capillary walls. This can be seen in mercury-induced MN due to the following reasons: (1) The ability of metal ions to ignite an inflammatory response without mitogens is very much established. Evidence for this comes from studies of metal-induced inflammation by beryllium exposure, where the proposed cellular mechanism involved is the activation of the innate immune system via cell death, engagement of pattern recognition receptors, migration of antigen-presenting cells to secondary lymphoid organs, and subsequent activation of the adaptive immune system including IFN-γ producing Th1 CD4+ T cells. 5 Adaptive immunity mediated by mercury exposure requires components of the innate immune system, 6 arguing that understanding early events in metal-induced immune cell activation is essential for inflammation and immuno-pathology. There are studies where it is seen that mercuric chloride elicits in vitro lymphoproliferation in rabbits, 5 rats, and guinea pigs. (2) Mercury causes significant renal tubular toxicity, and it has been postulated that this leads to the release of self-antigens and an ensuing inflammatory response involving cytokine and autoantibody production. (3) Merucury ions cause structural damage to the glomerulus, resulting in exposure to PLA2R antigens. This leads to the genesis of anti-PLA2R antibodies, mimicking idiopathic/primary membranous nephropathy. Previous case reports/reviews mentioned mercury-induced membranous nephropathy and minimal change disease. Here, we report dual renal lesions like chronic interstitial nephritis and membranous nephropathy that highlight the magnitude of mercury-induced renal toxicity caused by the application of this adulterated skin cream. Hence, we should be alert to the possibility of mercury toxicity in patients presenting with new-onset proteinuria and question their use of such mercury-containing products. In patients with mercury-induced MN, it is not mandatory to have a negative PLA2R staining. Conclusion Inflammatory indicators, autoantibodies, and renal disease are among the adverse effects of human exposure to mercury in its different forms. Due to the absence of appropriate diagnostic criteria and the modest number of small-scale epidemiological investigations, a definitive link with one or more diagnosable autoimmune illnesses could not be established. Our case with dual renal lesions, particularly with PLA2R-positive MN, strengthens the understanding of mercury-induced inflammation and renal autoimmunity. Consent to participate Written informed consent was given by the patient. Consent to publish Written consent from the patient was taken for publishing the case after de-identifying and anonymizing all the patient identifiers. Data availability “No Data are associated with this article”. References 1. Doshi M, Annigeri RA, Kowdle PC, et al. : Membranous nephropathy due to chronic mercury poisoning from traditional Indian medicines: report of five cases. Clin. Kidney J. 2018 Jun 3; 12 (2): 239–244. PubMed Abstract | Publisher Full Text 2. Chakera A, Lasserson D, Beck LH, et al. : Membranous nephropathy after use of UK-manufactured skin creams containing mercury. QJM. 2011 Oct; 104 (10): 893–896. PubMed Abstract | Publisher Full Text 3. Oliveira DB, Foster G, Savill J, et al. : Membranous nephropathy caused by mercury-containing skin lightening cream. Postgrad. Med. J. 1987 Apr; 63 (738): 303–304. PubMed Abstract | Publisher Full Text | Free Full Text 4. Zhang L, Liu F, Peng Y, et al. : Nephrotic syndrome of minimal change disease following exposure to mercury-containing skin-lightening cream. Ann. Saudi Med. 2014 May-Jun; 34 (3): 257–261. PubMed Abstract | Publisher Full Text | Free Full Text 5. Pollard KM, Cauvi DM, Toomey CB, et al. : Mercury-induced inflammation and autoimmunity. Biochim. Biophys. Acta Gen. Subj. 2019 Dec; 1863 (12): 129299. PubMed Abstract | Publisher Full Text | Free Full Text 6. Pollard KM, Escalante GM, Huang H, et al. : Induction of Systemic Autoimmunity by a Xenobiotic Requires Endosomal TLR Trafficking and Signaling from the Late Endosome and Endolysosome but Not Type I IFN. J. Immunol. 2017; 199 : 3739–3747. PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 28 May 2024 ADD YOUR COMMENT Comment Author details Author details 1 Nephrology, Kasturba Medical College Mangalore Manipal Academy of Higher Education Manipal India, Karnatak, 575001, India 2 Medicine, Kasturba Medical College Mangalore Manipal Academy of Higher Education Manipal, Karnataka, 575001, India Bhushan C Shetty Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Muralidhara Yadiyal B Roles: Supervision, Validation, Visualization, Writing – Review & Editing Ashok Bhat M Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 28 May 2024, 13:545 https://doi.org/10.12688/f1000research.149755.1 Copyright © 2024 C Shetty B et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article C Shetty B, Yadiyal B M and Bhat M A. Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.12688/f1000research.149755.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 28 May 2024 Views 0 Cite How to cite this report: Canpolat N. Reviewer Report For: Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.5256/f1000research.164251.r329661 ) The direct URL for this report is: https://f1000research.com/articles/13-545/v1#referee-response-329661 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 06 Nov 2024 Nur Canpolat , Department of Pediatric Nephrology, Istanbul University-Cerrahpasa, Istanbul, Turkey Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.164251.r329661 This case report presents a 26-year-old man who developed renal autoimmunity, specifically membranous nephropathy and chronic interstitial nephritis, after using a mercury-containing skin cream. The report suggests a link between mercury exposure and renal autoimmunity, despite having stopped using the ... Continue reading READ ALL This case report presents a 26-year-old man who developed renal autoimmunity, specifically membranous nephropathy and chronic interstitial nephritis, after using a mercury-containing skin cream. The report suggests a link between mercury exposure and renal autoimmunity, despite having stopped using the cream months before diagnosis. Pathological findings include positive PLA2R staining in glomerular capillaries, supporting the potential for mercury to trigger immune responses in renal tissue. However, there are critical gaps in the documentation, particularly histological and immunofluorescent evidence, which limit the certainty of mercury's role in this pathology. I have detailed my comments below. The physical examination findings lack sufficient clinical detail, such as specific laboratory values and follow-up data such as mercury levels and proteinuria, limiting the clinical utility of the report. The patient had stopped using mercury-containing creams three months prior to admission and mercury levels were normal at the time of assessment. This temporal gap and the lack of documentation of mercury levels at the onset of symptoms creates uncertainty about the direct role of mercury in the observed renal damage. This situation needs to be well analysed. The renal pathology figures show only a few glomeruli, which limits the reliability of the case. In particular, there is a lack of PAS staining and IF images for IgG, C3 and PLA2R that could confirm the presence of deposits. This lack weakens the conclusions regarding the role of mercury in renal pathology. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: pediatric nephrology, dialysis, chronic kidney disease, hypertension I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Canpolat N. Reviewer Report For: Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.5256/f1000research.164251.r329661 ) The direct URL for this report is: https://f1000research.com/articles/13-545/v1#referee-response-329661 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Pollard M, Kono D and Hultman P. Reviewer Report For: Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.5256/f1000research.164251.r293920 ) The direct URL for this report is: https://f1000research.com/articles/13-545/v1#referee-response-293920 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 24 Jul 2024 Michael Pollard , Scripps Research Institute, LA Jolla, CA, CA, 92037, USA Dwight Kono , Immunology and Microbiology, Scripps Research Institute Immunology and Microbiology (Ringgold ID: 478079), San Diego, California, USA Per Hultman , Department of Biomedical and Clinical Sciences, Linkoping University, Linköping, Sweden Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.164251.r293920 The findings in this manuscript are not conclusive because there is incomplete pathology and documentation of the findings. There seems to be severe GN with obliteration on several glomeruli on the H&E slide but its not clear and it would ... Continue reading READ ALL The findings in this manuscript are not conclusive because there is incomplete pathology and documentation of the findings. There seems to be severe GN with obliteration on several glomeruli on the H&E slide but its not clear and it would be more convincing to include a PAS stain to check for deposits. Plus there are only a few glomeruli in the images. Also, there is not adequate evidence of membranous GN in the figure. The described IF staining with focal and segmental distribution of deposits should be shown. The PLA2R staining should also be shown. There is insufficient support to implicate mercury for the kidney pathology. Although the cream being used contained extremely high levels of mercury, the patient had stopped using it for more than 3 months before presentation and his mercury levels were within normal limits at that time. Additionally, those mercury levels were not provided nor were follow-up urine analysis including mercury levels and proteinuria. A minor issue is the reference values for Urea are missing. More detailed comments from clinical pathologists. In Fig. 1 the upper cortex of the kidney is dominated by chronic interstitial inflammation (moderate to advanced). But there appears to be only a single glomerulus, and only 60 % of the glomerulus cab be seen (upper corner). This glomerulus is severely damaged, there are no capillary structures. Instead, there is only a mass of fibrosis. This is the end-stage of a glomerulus, but still recognizable as a glomerulus. It gives no clue of underlying process causing the damage. In the middle of the picture is a mass of cells. This might be a reaction of the inflammation, or possibly may be a glomerulus and/or tubular structure which is not recognizable. Again, no clue of underlying process. In Fig. 2 there are two glomerular structures which are situated to the left, and in the middle of the biopsy, and another to the left, down in the corner. In the first glomerulus, only half of it is recognizable. With the 2nd of the glomeruli the capillaries are intact, no proliferation of the podocytes or membranes. By light microscopy it is not possible to diagnose early stages of membranous glomerulonephritis, at least with this magnification. Thus Fig 1 shows chronic interstitial nephritis (moderate) and a single end-stage glomerulus, while Fig. 2 shows parts of two glomeruli, little pathological changes with chronic interstitial nephritis (moderate). Images for immunofluorescence of IgG and C3, and PLA2R should have been shown and electron microscopy performed. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: Autoimmunity associated with exposure to environmental/occupational exposures. We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Pollard M, Kono D and Hultman P. Reviewer Report For: Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.5256/f1000research.164251.r293920 ) The direct URL for this report is: https://f1000research.com/articles/13-545/v1#referee-response-293920 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 28 May 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 28 May 24 read read Michael Pollard , Scripps Research Institute, LA Jolla, CA, USA Dwight Kono , Scripps Research Institute Immunology and Microbiology (Ringgold ID: 478079), San Diego, USA Per Hultman , Linkoping University, Linköping, Sweden Nur Canpolat , Istanbul University-Cerrahpasa, Istanbul, Turkey Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Canpolat N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 06 Nov 2024 | for Version 1 Nur Canpolat , Department of Pediatric Nephrology, Istanbul University-Cerrahpasa, Istanbul, Turkey 0 Views copyright © 2024 Canpolat N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This case report presents a 26-year-old man who developed renal autoimmunity, specifically membranous nephropathy and chronic interstitial nephritis, after using a mercury-containing skin cream. The report suggests a link between mercury exposure and renal autoimmunity, despite having stopped using the cream months before diagnosis. Pathological findings include positive PLA2R staining in glomerular capillaries, supporting the potential for mercury to trigger immune responses in renal tissue. However, there are critical gaps in the documentation, particularly histological and immunofluorescent evidence, which limit the certainty of mercury's role in this pathology. I have detailed my comments below. The physical examination findings lack sufficient clinical detail, such as specific laboratory values and follow-up data such as mercury levels and proteinuria, limiting the clinical utility of the report. The patient had stopped using mercury-containing creams three months prior to admission and mercury levels were normal at the time of assessment. This temporal gap and the lack of documentation of mercury levels at the onset of symptoms creates uncertainty about the direct role of mercury in the observed renal damage. This situation needs to be well analysed. The renal pathology figures show only a few glomeruli, which limits the reliability of the case. In particular, there is a lack of PAS staining and IF images for IgG, C3 and PLA2R that could confirm the presence of deposits. This lack weakens the conclusions regarding the role of mercury in renal pathology. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? No Competing Interests No competing interests were disclosed. Reviewer Expertise pediatric nephrology, dialysis, chronic kidney disease, hypertension I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Canpolat N. Peer Review Report For: Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.5256/f1000research.164251.r329661) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-545/v1#referee-response-329661 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Pollard M et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 24 Jul 2024 | for Version 1 Michael Pollard , Scripps Research Institute, LA Jolla, CA, CA, 92037, USA Dwight Kono , Immunology and Microbiology, Scripps Research Institute Immunology and Microbiology (Ringgold ID: 478079), San Diego, California, USA Per Hultman , Department of Biomedical and Clinical Sciences, Linkoping University, Linköping, Sweden 0 Views copyright © 2024 Pollard M et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The findings in this manuscript are not conclusive because there is incomplete pathology and documentation of the findings. There seems to be severe GN with obliteration on several glomeruli on the H&E slide but its not clear and it would be more convincing to include a PAS stain to check for deposits. Plus there are only a few glomeruli in the images. Also, there is not adequate evidence of membranous GN in the figure. The described IF staining with focal and segmental distribution of deposits should be shown. The PLA2R staining should also be shown. There is insufficient support to implicate mercury for the kidney pathology. Although the cream being used contained extremely high levels of mercury, the patient had stopped using it for more than 3 months before presentation and his mercury levels were within normal limits at that time. Additionally, those mercury levels were not provided nor were follow-up urine analysis including mercury levels and proteinuria. A minor issue is the reference values for Urea are missing. More detailed comments from clinical pathologists. In Fig. 1 the upper cortex of the kidney is dominated by chronic interstitial inflammation (moderate to advanced). But there appears to be only a single glomerulus, and only 60 % of the glomerulus cab be seen (upper corner). This glomerulus is severely damaged, there are no capillary structures. Instead, there is only a mass of fibrosis. This is the end-stage of a glomerulus, but still recognizable as a glomerulus. It gives no clue of underlying process causing the damage. In the middle of the picture is a mass of cells. This might be a reaction of the inflammation, or possibly may be a glomerulus and/or tubular structure which is not recognizable. Again, no clue of underlying process. In Fig. 2 there are two glomerular structures which are situated to the left, and in the middle of the biopsy, and another to the left, down in the corner. In the first glomerulus, only half of it is recognizable. With the 2nd of the glomeruli the capillaries are intact, no proliferation of the podocytes or membranes. By light microscopy it is not possible to diagnose early stages of membranous glomerulonephritis, at least with this magnification. Thus Fig 1 shows chronic interstitial nephritis (moderate) and a single end-stage glomerulus, while Fig. 2 shows parts of two glomeruli, little pathological changes with chronic interstitial nephritis (moderate). Images for immunofluorescence of IgG and C3, and PLA2R should have been shown and electron microscopy performed. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? No Competing Interests No competing interests were disclosed. Reviewer Expertise Autoimmunity associated with exposure to environmental/occupational exposures. We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Pollard M, Kono D and Hultman P. Peer Review Report For: Case Report: Mercury-induced renal autoimmunity – An insight into its pathogenesis [version 1; peer review: 2 not approved] . F1000Research 2024, 13 :545 ( https://doi.org/10.5256/f1000research.164251.r293920) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-545/v1#referee-response-293920 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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last seen: 2026-05-20T01:45:00.602351+00:00