Abstract: FR-PO0754
An Unusual Overlap: Phospholipase A2 Receptor (PLA2R) Antibody-Positive Membranous Nephropathy with Crescentic Glomerulonephritis in a Patient Using Levamisole-Adulterated Cocaine
Session Information
- Glomerular Diseases: ANCA Vasculitis, Anti-GBM Disease, and Crescentic GN
October 23, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Chen, Kevin D., UCSF Health, San Francisco, California, United States
- Macaraeg, Lauren Eillen, UCSF Health, San Francisco, California, United States
Introduction
Overlap between PLA2R-positive membranous nephropathy and crescentic glomerulonephritis is rare. The renal manifestations typically observed with cocaine use, specifically levamisole-adulterated cocaine, involve ANCA associated vasculitis with pauci-immune crescentic glomerulonephritis. There is no population-based incidence data that exists for levamisole-induced membranous nephropathy, with the literature limited to case reports and case series, suggesting this is a rare complication. PLA2R positive membranous nephropathy is typically considered in the context of primary autoimmune disease, but levamisole use causing PLA2R positive membranous nephropathy with superimposed crescentic glomerulonephritis has not been well established in the literature.
Case Description
We illustrate a case of a 39-year-old male with chronic cocaine use who presented with respiratory failure in the setting of volume overload and oliguric acute kidney injury. His initial labs were notable for a BUN 110, Cr 13.97, eGFR < 5, BNP 2999, and proteinuria 300-600 mg/dL. He was initiated on hemodialysis for metabolic and volume control. Kidney biopsy was diagnostic for PLA2R-positive membranous glomerulonephritis with superimposed crescentic glomerulonephritis, with cellular crescents involving greater than 50% of glomeruli. He was initiated on a steroid pulse followed by cyclophosphamide with the modified Ponticelli regimen.
Discussion
This case highlights the significant diagnostic and pathophysiologic challenge at the intersection of immune complex-mediated and pauci-immune glomerular disease. The presence of PLA2R positivity strongly supports a diagnosis of primary membranous nephropathy, but in this case, it appears that his membranous nephropathy is secondary to cocaine use. What is more interesting is this additional finding of seronegative crescentic glomerulonephritis. In the literature, the most common glomerular pathology associated with cocaine use is pauci-immune crescentic glomerulonephritis with ANCA positivity. Given the severity of his presentation, we decided to pursue the modified Ponticelli regimen. This case highlights the complexity of glomerular pathology that can be seen with levamisole-adulterated cocaine use and describes a unique presentation of PLA2R-positive membranous nephropathy with superimposed crescentic glomerulonephritis and its subsequent management.
Acknowledgment
We sincerely thank UCSF Stanyan Internal Medicine Residency Program for their support in the development of this project, particularly Dr. Terrie Mendelson and Dr. Lauren Macaraeg for their mentorship and guidance.