WHEN ANCA-ASSOCIATED VASCULITIS MET COVID-19: A CASE REPORT

ABSTRACT

The ANCA-associated vasculitis (AAV) shares similar pathophysiological pathways with SARS-CoV-2 infection such as neutrophil extracellular traps, complement cascades, and IL-6. Patients with AAV have a higher risk for SARS-CoV-2 infection. In turn, the viral infection could trigger the relapse of AAV. We are presenting a case of a SARS-CoV-2 infection who developed relapsing AAV and discussion about management. A 25-year-old Hispanic male who was recently diagnosed with X-ANCA vasculitis with diffuse alveolar hemorrhage (DAH), AKI treated with pulse steroids, plasmapheresis (PLEX), two doses of rituximab (375mg/kg) was admitted with fever, hemoptysis, hypoxemia, and positive COVID-19 nasopharyngeal swab. Due to DAH and worsening oxygen requirements by day 3, IV pulse methylprednisolone 1000mg x3, rituximab 1g x2 and PLEX x 5 given, and on day 6 convalescent plasma was given. He developed non-oliguric AKI on CKD due to acute tubular injury superimposed on biopsy proven pauci-immune necrotizing crescentic glomerulonephritis needing hemodialysis from day 8 to 18. On day 9, patient developed ARDS requiring BiPAP and increased inflammatory markers, secondary to cytokine storm and got two dose of tocilizumab (8mg/kg). After this patient improved clinically and was discharged on room air with improving serum creatinine from peak 5.98mg/dL to 3.94mg/dL with oral prednisone of 60mg daily. The treatment for the AAV in the setting of COVID-19 has been controversial. Though the risk of infection increases with Rituximab use, current literature supports cautious use of the B-cell depleting agents for AAV indications during the pandemic with favorable riskbenefit ratio. Tocilizumab may also have dual beneficial effects in treating the AAV flare and managing the cytokine storm of COVID infection. Our case study showed this presumed dual benefit. Large scale studies are required to both prove the safety of Rituximab use in the setting of risk of COVID infection and Tocilizumab use for AAV flare with COVID infection. Clinicians should not shy away from using the Rituximab in AAV treatment due to the ongoing pandemic as the risk of not using may be much worse where it is clinically indicated. Tocilizumab may have dual beneficial effects of treating the Cytokine storm and AAV flare as we saw in our case.