A Case of Primary Membranous Nephropathy (MN) After Booster Injection of the BNT162b2 COVID-19 Vaccine (Pfizer-BioNTech)

ABSTRACT

Introduction: All currently authorized COVID-19 vaccines have proven to be safe, effective and reduce risk of severe illness. Glomerular disease have been reported after administration of COVID-19 messenger RNA (mRNA) vaccines. We report on the development of nephrotic syndrome from Primary Membranous nephropathy after third injection of the BNT162b2 COVID-19 vaccine. Case Description 34 years old female with no significant past medical history except migraine headaches, presented to the outpatient setting reporting intermittent and gradually progressing lower extremities edema for 3 months;accompany by abdominal and lower back swelling, facial edema and foamy urine. She received her 3rd dose of COVID-19 vaccine 1-2 weeks before symptoms appearance. On evaluation, she was normotensive, preserved kidney function(Creatinine 0.85 BUN 9 eGFR >60), hypoalbuminemia (Alb 1.1 g/dL), nephrotic-range proteinuria (Spot urine protein 869.9 mg/dL, Urine Creatinine 79.9mg/dL, 24hr Urinary protein excretion estimation 11000mg/g [11g/day]), elevated cholesterol (572mg/dL) and triglycerides (220 mg/dL). She has negative ANA, ANCA, DNA Ds Ab, Hepatitis profile, HIV. Her Anti-phospholipase A2 receptor (anti- PLA2R) antibody came back positive (247 relative units/ml [<14, negative;>20, positive]) She underwent kidney biopsy showing global 3+ Subendothelial electron dense deposits (IgG, C3, Kappa, Lambda), 100 % foot process effacement, IF staining positive for PLA2R, consistent with Primary Membranous Nephropathy Stage II. She was started on High-dose steroids and later switched to Tacrolimus 2mg BID, and received Rituximab x 2 doses with major improvement in symptoms and proteinuria. Discussion(s) MN is more common in male in their early 50s. The fact our patient doesn't fit this category, her temporal association with vaccination and the exclusion of other explanatory factors, supports a potential connection between COVID-19 vaccination and glomerular disease. To our knowledge, this is only the second case reporting association of COVID-19 mRNA vaccine and MN. Together with a report from Relapse MN after vaccination and one case of Minimal Change disease, we highlight the possible role of COVID vaccination causing immune glomerular dysregulation. Further studies are needed to elucidate the early postvaccination immune response mechanism.