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Abstract: TH-PO470

Syphilis and HIV Co-Infection: A Dual Attack on the Kidneys

Session Information

Category: Glomerular Diseases

  • 1302 Glomerular Diseases: Immunology and Inflammation

Authors

  • Dorobisz, Sylvester, Cleveland Clinic, Cleveland, Ohio, United States
  • Mehdi, Ali, Cleveland Clinic, Cleveland, Ohio, United States
  • Thomas, George, Cleveland Clinic, Cleveland, Ohio, United States
  • Tomaszewski, Kristen, Cleveland Clinic, Cleveland, Ohio, United States
  • Ferreira Provenzano, Laura, Cleveland Clinic, Cleveland, Ohio, United States
  • George, Michael W., Cleveland Clinic, Cleveland, Ohio, United States
Introduction

HIV-associated nephropathy (HIVAN) remains an important cause of kidney failure in persons of African ancestry due to the association with APOL1. Syphilis infections are increasing in incidence and have notable kidney manifestations. Here we present a case of kidney failure in the setting of an HIV and syphilis co-infection.

Case Description

A 54-year-old black male presented to the emergency department with recurrent chest pain and malaise. His cardiac evaluation was unrevealing but he had lower extremity edema on examination. His creatinine on presentation was 1.5mg/dl (baseline: 1.1mg/dl) increasing to 5.83mg/dl during the hospitalization. A urinalysis had 3+ proteinuria and 3+ hematuria and urine protein creatinine ratio was 8.2 g/g. A kidney ultrasound revealed no hydronephrosis. His albumin was 1.8 g/dL and serologic work up revealed negative ANA, ANCA, M protein, PLA2R antibodies, hepatitis panel and normal complements. An HIV test was negative a week prior. His CBC was normal but he had a depleted haptoglobin and elevated LDH at 969 U/L. A kidney biopsy revealed focal segmental glomerulosclerosis with collapsing and membranous features along with acute tubular injury and mild interstitial fibrosis. Immunofluorescence was negative. An HIV RNA test came back positive at 1,980,000 copies/mL suggesting an acute retroviral illness. Syphilis screen also came back positive. It was thus thought that the HIV accounted for the collapsing features while the syphilitic infection led to the membranous component. Along with diuresis for volume overload, antiretroviral therapy and penicillin were started. His creatinine stabilized at 2 mg/dl at outpatient follow-up with improving proteinuria.

Discussion

Both syphilis and HIV can cause proteinuric kidney injury. HIVAN is well described with glomerular collapsing features on biopsy in the setting of uncontrolled HIV. This case illustrates that HIVAN can also occur in the setting of an acute HIV infection where the HIV screening test can be negative. HAART therapy remains the cornerstone of management with unfavorable prognosis. Membranous nephropathy is the most common pathologic finding of syphilitic nephropathy with excellent response to syphilis treatment. This case serves as a reminder to consider this entity in our differentials particularly with the resurgence of this infection.