Aki and purpuric rash in a COVID patient

ABSTRACT

Introduction: AKI in COVID-19 patients are reported in several studies with an incidence of 23%. We report a case of COVID-19 pneumonia with AKI and purpuric rash. Case Description A 54 y/o female with hypertension, CKD stage 3, with a COVID+ swab, presented with CT chest findings consistent with COVID-19 pneumonia, purpura of the lower limbs concerning for leukocytoclastic vasculitis and non-oliguric AKI. Creatinine on admission was 8.5mg/dl, (baseline of 1.6mg/dL), CBC showed a wbc 26.9, Hb 6.9, platelets 196 and eosinophilia. Serologies were notable for elevated direct coomb, low haptoglobin, low C3/C4, and rheumatoid factor of 26. UA had no hematuria, UPCR 0.75 mg/mg. Home medication, naproxen was stopped one month ago. Renal biopsy showed severe acute tubular injury (ATI), coarse vacuolization of tubular epithelial cells, severe leukocytic infiltration of lymphocytes, neutrophils, eosinophils, severe vascular hyalinosis, global glomerular sclerosis (11 out of 30 glomeruli), severe (60%) interstitial fibrosis & tubular atrophy. Per institutional protocol, Immunofluorescence could not be performed in COVID+ patients. Renal function improved significantly after a 5 day course with IV steroids alone and patient remained stable with a creatinine of 3.4 mg/dL. Discussion: This case features multiple potential mechanisms for AKI in a COVID-19 patient. Viral effects include, acute interstitial nephritis (AIN), severe ATI, and endothelial inflammation leading to vasculitis and purpuric rash. Recently, vasculitis similar to Kawasaki disease has been described in COVID-19 patients. Our case suggests that immune dysregulation from COVID infection may result in autoimmune findings such as elevated RF and hemolytic anemia. AKI improved in our patient after steroids, suggesting that a biopsy with features of AIN should be treated and could change the course of the disease.