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Abstract: TH-PO696

An Interesting case of Membranous Nephropathy in a Patient with Diffuse Alveolar Hemorrhage and Cocaine Use: A Case Report

Session Information

Category: Glomerular Diseases

  • 1402 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Jangam, Kadambari, UPMC McKeesport, McKeesport, Pennsylvania, United States
  • Srinivasa, Nangali S., UPMC East, Monroeville, Pennsylvania, United States
Introduction

Membranous nephropathy (MN) is a common cause of nephrotic syndrome in adults. 70-80% of the cases are primary. We present a case of primary membranous nephropathy in a patient with cocaine use disorder presenting with diffuse alveolar hemorrhage and acute renal injury.

Case Description

A 60-year-old woman with a medical history of HTN, asthma, and cocaine use presented with left-sided chest pain after a mechanical fall following alcohol and cocaine consumption. Trauma work-up: no fracture. CT chest: multifocal pneumonia. Serum Cr: 3.25(baseline: 0.8-1.2), UA: mild proteinuria-30 mg/g, no casts. Her hospital course was complicated by severe ARDS requiring intubation, septic shock, and worsening renal function with oliguria. Repeat UA: proteins>300mg/g, no casts. Serum Cr: 2.25/BUN: 53/K+: 5.4/HCO3: 21. Hemodialysis(HD) was initiated for volume overload. Bronchoscopy showed diffuse alveolar hemorrhage.

Serology: positive ANA(1:40), anti-RNP/Sm antibody(3.1). RF complement levels, anti-MPO, ANCA, lupus antibodies, lupus anticoagulant antibodies, Sjogren’s antibodies, anti-JO-1, scleroderma, anti-proteinase-3 antibody, anti-DNAase, anti-smooth muscle, anti-GBM, cryoprecipitate, RPR test, IgG, IgM antibodies were negative. Hepatitis B core antibody, CMV DNA was positive. VATS biopsy demonstrated scattered hemorrhagic infarct with organizing pneumonia. Kidney biopsy revealed stage 3/4 membranous nephropathy with focal segmental sclerosis. Presence of co-dominant IgG1 and IgG3 subclass and IgG4 and PLA2R staining of the GBM immune deposits, and few mesangial immune complex deposits. CPK: normal. Anti-PLA2-R resulted in positive.

Following high-dose steroids, she is now on steroid taper and on intermittent HD due to poor renal recovery.

Discussion

Diffuse alveolar hemorrhage and nephrotic range proteinuria prompted testing to rule out pulmonary-renal syndromes, which were unsatisfactory; a mildly positive ANA could be secondary to an acute illness. Electron microscopy and immunofluorescence findings of kidney biopsy were inconsistent. IgG1 and IgG3 subclass staining of the GBM immune deposits suggested lupus membranous nephropathy; IgG4 and PLA2R staining suggested primary membranous nephropathy. Despite risk factors for secondary MN(Hep B positive, levamisole with cocaine exposure) a positive Anti-PLA2-R made the diagnosis of primary MN.