Crescentic IgA Nephropathy (cIgAN) in a Patient With COVID-19 Infection

ABSTRACT

Introduction: COVID19 infection has been linked to various glomerulonephropathies (GN) including collapsing focal segmental glomerulosclerosis, pauciimmune crescentic glomerulonephritis, and possibly minimal change disease and IgA nephropathy. Case Description A 57-year-old obese man with hypertension, hyperlipidemia, prediabetes, chronic obstructive pulmonary disease, illicit drug use, status post Pfizer COVID vaccine (1st dose 4m prior, 2nd dose 3w later), and COVID19 infection 7w prior, presented with an acute onset purpuric rash that began from bilateral hands and feet and progressed to arms and legs. Patient denied joint pain or abdominal discomfort. Initial studies Serum creatinine (Cr) 4.17 mg/dL (2.37 mg/dL 2w prior, baseline 0.93 mg/dL 4m prior). Urinalysis > 50 red blood cells/high power field;Urine protein/Cr 4g/g, albumin/Cr >3g/g;Negative HIV, ANCA, ANA, antiGBM, complements. Chest CT Bilateral multifocal consolidative opacities concerning for aspiration, multifocal bacterial or viral pneumonia, or atypical presentation of COVID19 pneumonia. Skin biopsy Leukocytoclastic vasculitis;No immunoreactants detected. Patient suffered from rapid respiratory deterioration, multiple hypotensive episodes, and acute kidney injury requiring mechanical ventilation and dialysis support. Kidney biopsy IgA dominant immune complex mediated glomerulonephritis with focal/remote fibrous crescents;acute tubular injury. Treatment Intravenous methylprednisolone 250 mg x 3d, followed by oral prednisone course. Patient recovered adequate function after 6w and was able to discontinue dialysis. Discussion(s) COVID19 infection-related inflammatory response may precipitate GN in susceptible individuals. Crescentic IgAN is known to be associated with acute inflammatory conditions involving lungs, gastrointestinal tract, and skin. The timeline for the development of cIgAN herein raises suspicion for COVID19 infection/pneumonia as the inciting event. (Figure Presented).