ABSTRACT
Introduction: A 24 year old male presented with rash, gastrointestinal bleeding and nephrotic syndrome one week after first COVID vaccination. Renal biopsy revealed crescentic IgA nephritis. He was treated steroids and responded clinically but continues to have proteinuria. Case Description: A 24 year old male with history of cerebral palsy presented with a vasculitic rash, hematochezia and edema. He had no prior history of renal or autoimmune disease. Symptoms developed one week after first dose of Moderna mRNA-1273 vaccine. Serum albumin was 1.6 g/dL and urine protein-creatinine ratio 8.5. Endoscopy showed esophagitis and small bowel ulcerations. Renal biopsy showed focally crescentic and necrotizing proliferative glomerulitis with IgA dominant deposits consistent with IgA vasculitis with renal involvement. He received pulse dose solumedrol followed by prednisone taper. Cyclophosphamide was initiated but then stopped due to cytopenias. After several weeks GI bleeding resolved spontaneously and proteinuria improved but remained in the nephrotic range. The course was further complicated by positive COVID testing prior to discharge-he was asymptomatic and received sotrovimab. On followup three months later the patient's edema resolved and serum albumin normalized. He continues to have subnephrotic range proteinuria with 2.3 grams/24 hours and active urinary sediment with dysmorphic red cells. He remains on steroid taper with plan for repeat renal biopsy to inform decisions regarding further immune suppression. He has not been rechallenged with COVID vaccine. Discussion(s): Rare associations between COVID vaccination and both de-novo and relapsing glomerular lesions, including minimal change disease, IgA nephropathy, ANCA and anti GBM glomerulonephritis, have been reported. COVID infection itself has been associated with an FSGS type lesion termed COVID-associated nephropathy (COVAN). As highlighted by this case, unvaccinated or partially vaccinated patients are at increased risk for COVID infection. Thus even in those with known glomerular disease, vaccination should still be recommended. Studies are needed to determine if patients with off-target glomerulopathies can be safely rechallenged with COVID vaccine, whether the course of COVID vaccine-associated disease glomerular lesions mimic the primary glomerular disease and how to optimally manage these patients.