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Abstract: PO1618

Schistosomiasis in a Patient on Rituximab for ANCA-Associated Glomerulonephritis

Session Information

Category: Glomerular Diseases

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Jovanovic, Milica, Metropolitan Hospital Center, New York, New York, United States
  • Aameish, Muhammad Umer Shahzad, Metropolitan Hospital Center, New York, New York, United States
  • Baumstein, Donald I., Metropolitan Hospital Center, New York, New York, United States
  • Chaudhari, Ashok P., Metropolitan Hospital Center, New York, New York, United States
Introduction

Rituximab and glucocorticoids induce remission in ANCA associated vasculitis with renal involvement. Rituximab induces B-cell depletion and influences T-cell immunity, which predispose patients to serious infectious complications. We present a case of schistosomiasis in a patient on rituximab for Pauci Immune Glomerulonephritis (GN) associated with ANCA vasculitis.

Case Description

A 39 years old female from Honduras with history of sero-negative arthritis, acute kidney injury with pauci immune, focal necrotizing and diffuse crescentic GN on kidney biopsy
and P-ANCA positive, was treated on rituximab and glucocorticoids. Ten months later, while in remission she presented with nausea, vomiting, obstipation and abdominal pain. Her labs showed, Hgb: 10.4g/dl, WBC: 6780/mcl , Eosinophils 25%, Cr: 0.7mg/dl, H. Pylori: Positive. Guaic negative. Stool negative for ova/parasites. Endoscopy showed non-bleeding erosive gastropathy with scattered punctate ulcerations in the duodenum. On biopsy diffuse acute and chronic inflammation, focal cryptitis, erosion of mucosa, Schistosoma Mansoni ova in glands of stomach, duodenum and jejunum were noted. CT brain negative for cysticercosis. CT chest showed calcified granulomas in right middle lobe and right lower lobe. On reevaluation she admitted to consuming snails.
Rituximab maintenance therapy was not continued because of schistosomiasis. She was admitted for a multidisciplinary approach. Renal function remained stable protein/creatinine ratio 0.8, Myeloperoxidase negative .
Patient was started on Praziquantel 1.2 g tid and prednisone 60 mg for 5 days which was followed by another cycle after 4 weeks to treat any remaining adult schistosomes. Repeat EGD and colonoscopy with multiple biopsies to ensure eradication of schistosomiasis before resuming rituximab is planned.

Discussion

Our case emphasizes the need to consider parasitic infections when starting patients from endemic areas on immunosuppressive therapy. Schistosomiasis can involve multi-organ systems and can lead to potentially debilitating and fatal complications such as liver fibrosis, portal hypertension, hypersplenism, esophageal variceal bleeding, GN and nephrotic syndrome. Detailed history for dietary habits and lifestyle is important. Serology, antigen detection or other diagnostic tools can be used when the suspicion is high.