Anca-associated glomerulonephritis and vasculitis following COVID-19 vaccination in a patient with giant cell arteritis

ABSTRACT

Introduction: A 66-year-old man with history of hypertension, chronic obstructive pulmonary disorder, latent tuberculosis, and biopsy-proven giant cell arteritis (GCA) was admitted for fevers and intermittent headaches three weeks after receiving dose 2 of the Moderna COVID-19 vaccine. Case Description On admission, the patient was afebrile with normal vitals and unremarkable physical examination. He noted his GCA had been in remission off treatment for two years. Labs noted new-onset microscopic hematuria and proteinuria (1.5 g/24 hr) as well as serum creatinine (SCr) of 2.2 mg/dL from 1.4 ten days prior. His sedimentation rate and C-reactive protein were also markedly elevated (119 mm/hr and 105 mg/L). Given rapidly progressive glomerulonephritis, IV Solumedrol was given for 3 days (after infection was ruled out). A kidney biopsy showed pauci-immune, necrotizing, crescentic glomerulonephritis and small vessel vasculitis (Figure 1A & 1B). Serologies returned with positive p-ANCA and high-titer myeloperioxidase antibody, confirming the diagnosis of Microscopic polyangiitis (MPA). He was transitioned to oral Prednisone and given the first of two doses of IV Rituximab. One week post-biopsy his SCr was 1.8 mg/dL. Discussion: Renal involvement by MPA in patients with GCA is rare but has been reported. This case is unique in its temporal relation to COVID-19 vaccination. There have been reports of crescentic IgA nephropathy as well as minimal change disease following COVID-19 vaccination but we are unaware of cases of de novo or recurrent vasculitis. While causality is difficult to prove, clinicians should closely monitor patients post-vaccination.