Outcomes from Acute Co-Infection of HIV and Hepatitis B Infection Nephritic Syndrome
- Glomerular Diseases: From Inflammation to Fibrosis - II
November 03, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1401 Glomerular Diseases: From Inflammation to Fibrosis
- Sasidharan, Sandeep Raja, SUNY Downstate Health Sciences University, New York City, New York, United States
- Jatoi, Tahir Ahmed, SUNY Downstate Health Sciences University, New York City, New York, United States
- Abushawer, Mohammad Waleed, SUNY Downstate Health Sciences University, New York City, New York, United States
- Puri, Isha, SUNY Downstate Health Sciences University, New York City, New York, United States
- Seshan, Surya V., Weill Cornell Medicine, New York, New York, United States
- Saggi, Subodh J., SUNY Downstate Health Sciences University, New York City, New York, United States
We present a unique case of a previously untreated combined HIV and HBV coinfection presenting as HD requiring AKI with Nephritic syndrome and significant lymphoplasmacytic interstitial inflammation with dominant for CD8 T lymphocyte.
40-year-old AA male with no past history who presented with anasarca, 3+ proteinuria and uremic symptoms of nausea/vomiting for 1-2 weeks. Labs significant for BUN/Cr 56/5.1, Alb <1.5, Urine Prot >500, Hgb 5.8, C3 64, C4 122, CD4 141. SPEP and UPEP negative. Hep B and HIV viral quantitative PCR were 7.7million virions and 280,000. Negative for other serologies.
Biopsy showed HIVAN with FSGS and microcystic tubular changes, MPGN, diffuse interstitial lymphocytosis syndrome (DILS) with dominant CD8 cells along with lymphoplasmacytic infiltration.
He needed emergent HD for AKIN Stage 3 and anasarca unresponsive to diuretics, on retrovirals without renal response until he was started on a course of steroids, serendipitously for high intracranial pressures from Acute Toxoplasmosis on his second admission.
DILS is a rare multisystemic syndrome characterized by CD8+ lymphocytosis associated with a CD8+ T-cell infiltration of multiple organs, usually seen in uncontrolled or untreated viral infections but can also manifest itself independently of CD4+ T-cell counts.
The rarity of DILS cases explains the lack of studies describing treatment options but the consensus is that the primary treatment line should be HAART. Specifically, for the renal condition, several case reports suggest the use of corticosteroid therapy. This is congruent with other studies showing initial response may be dramatic with corticosteroids adjunct to ART +/- ACEi/ARB, even reversing dialysis dependence, but transient. Comorbid kidney disease in the setting of HIV/HBV is challenging to manage clinically because the preferred antiretroviral agent in coinfection, tenofovir disoproxil fumarate (TDF), is potentially nephrotoxic. However, in immune-tolerant HBV, steroids could reactivate severe infection.
In the current era of retroviral availability, it is extremely rare to see a case of classical HIVAN and DILS. Our case is unique as the patient had 2 viral infections and lymphocyte pattern of CD8 lineage that coincidentally responded to high-dose steroids which were given for other reasons.