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Abstract: PO1865

Infection-Related Glomerulonephritis Mimicking Lupus Nephritis

Session Information

Category: Trainee Case Report

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Alawieh, Rasha, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
  • Satoskar, Anjali A., The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
  • Ayoub, Isabelle, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Introduction

Differentiating infection vs auto-immune related GN is crucial in order to avoid inadvertent immunosuppressive therapy that can be harmful and even lead to fatal consequences. This case illustrates the dilemma of medical management in lupus like-GN

Case Description

A 66 year old man with mitral valve prolapse, was found to have elevated creatinine of 3.59 mg/dl from a baseline of 1 mg/dL. He complained of leg rash and dark urine. His rash was symmetric and non blanchable petechiae. Urine sediment showed 20 dysmorphic RBC per high-power field and RBC casts. Urine protein/creatinine ratio was 1.35 g/g. Serum creatinine peaked at 10.4 mg/dl. Hemodialysis was begun. Further testing was significant for pancytopenia, low complements (C3 was 40 mg/dl, C4 10 mg/dl) and positive MPO-ANCA. Kidney biopsy was performed (Fig 1). On light microscopy 2 glomeruli were globally sclerotic. One glomerulus showed crescentic and necrotizing lesion. There was diffuse ATN. Some tubules showed red blood cell casts. Interstitial inflammation was mild. Direct IF showed a full house pattern with bright IgG, IgM, kappa, lambda, C1q, C3 and mild to moderate IgA staining. EM identified few mesangial and subendothelial deposits with a single subepithelial hump. During his hospitalization, streptococcus bacteremia was documented. Echo showed mitral valve vegetation. In setting of bacterial endocarditis, the Biopsy is consistent with infection related glomerulonephritis (IRGN).

Discussion

Crescents as well as ANCA positivity have been described in IRGN. However a full-house immunostaining pattern is not typical of IRGN and has never been reported in IRGN. Instead, this is typical of lupus- like GN. The patient didn’t have positive ANA, however he developed pancytopenia and hypocomplementemia which can be manifestations of both SLE even at an old age as well as infection. The dilemma is that auto-immune mediated GN warrants immunosuppressive therapy which is contraindicated in IRGN. Our patient received penicillin and underwent mitral valve replacement His kidney function gradually improved and dialysis was discontinued after 4 months.