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Abstract: TH-PO699

Not So "Golden": A Case of Mercury-Associated NELL-I-Positive Membranous Nephropathy

Session Information

Category: Glomerular Diseases

  • 1402 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Atefi, Nazli, University of Maryland School of Medicine, Baltimore, Maryland, United States
  • Tuchler, Amanda M., University of Maryland School of Medicine, Baltimore, Maryland, United States
  • Syed, Hassan, University of Maryland School of Medicine, Baltimore, Maryland, United States
  • Douglas, Taylor, University of Maryland School of Medicine, Baltimore, Maryland, United States
  • Drachenberg, Cinthia, University of Maryland School of Medicine, Baltimore, Maryland, United States
  • King, Joshua D., University of Maryland School of Medicine, Baltimore, Maryland, United States
Introduction

Mercury is a heavy metal that exists in various forms and can be encountered through multiple pathways of exposure. Inorganic mercury is associated with glomerular disease - particularly membranous nephropathy (MN) - as well as peripheral neuropathy. In recent years, inorganic mercury in skin lightening creams has been associated with neural epidermal growth factor-like 1 protein (NELL-1) positive MN; very few cases are reported from the United States. We report a case of skin lightening cream-associated mercury toxicity and NELL-1 positive MN.

Case Description

A 41-year-old female with type 2 diabetes who emigrated from Afghanistan 2 years prior presented with 6 months of progressive leg edema, worsening proteinuria, and long-standing peripheral neuropathy. Four months before presentation, albumin/creatinine ratio (ACR) was 6,050 mg/g; immediately before presentation, ACR was 17,862 mg/g. Subsequent 24-hour urine protein was measured at 37.1 grams. Serum creatinine was 0.6 mg/dL.
On initial presentation, skin lightening cream use was queried; the patient produced a container of “Golden Pearl” beauty cream, found by the FDA to contain 12,000 ppm mercury, which she regularly used. Her blood and urine mercury levels were found to be elevated. Serologic studies included multiple negative serologic studies including anti-phospholipase A2 receptor (PLA2R) antibodies.
The patient was admitted to the hospital and treated with furosemide. A kidney biopsy was performed and was notable for MN, staining negative for anti-PLA2R and positive for NELL-1. Chelation with succimer was unable to be initiated due to cost; treatment with steroids is being arranged.

Discussion

Mercury-associated MN generally has a favorable prognosis with discontinuation of mercury use; steroids and chelation are the most common therapies utilized in the literature. Skin lightening creams may be used in the United States by immigrants from regions in which they are routinely used. In patients presenting with unexplained proteinuria from areas of the world where mercury-containing products are used, particularly with peripheral neuropathy, mercury toxicity should be considered and skin lightening cream use should be queried. Mercury-associated MN has an emerging association with NELL-1; mercury screening may be warranted in patients with NELL-1 positive MN.