Immune reconstitution, glomerulonephritis, and successful treatment with rituximab.

BACKGROUND: Alemtuzumab can induce secondary autoimmunity affecting multiple organs. While kidney involvement is uncommon, it can be associated with devastating forms of glomerulonephritis (GN). CASE PRESENTATION: A 32-year-old African American woman presented with hypertension, proteinuria, and progressive renal failure. Her medical history was remarkable for secondary progressive multiple sclerosis (SPMS). She had received her first induction dose of alemtuzumab 1 year prior to presentation. Upon evaluation, she had scanning speech, multidirectional nystagmus, and mild edema. Her serum creatinine was 2 mg/dL. Urine studies revealed proteinuria and microscopic hematuria. Her serologic tests were positive for c-antineutrophil cytoplasmic antibodies (> 1 : 640). In addition, she was found to have new-onset severe thyroid dysfunction with antibodies against thyroglobulin and thyroid peroxidase. Kidney biopsy was diagnostic for pauci-immune crescentic GN. The patient was treated with methylprednisolone and rituximab with subsequent renal, thyroid, and neurological recovery. CONCLUSION: This is an atypical case of GN following therapy with alemtuzumab. We hypothesize that immune reconstitution may be a potential mechanism. Alemtuzumab is a new treatment for SPMS that can be associated with GN. Practice guidelines should address the management of its renal complications.

Disseminated herpes zoster with acute encephalitis in an immunocompetent elderly man.

Varicella-zoster virus (VZV) encephalitis typically occurs in immunosuppressed populations such as in patients with HIV/AIDS, transplantation and autoimmune disease. However, it can also occur in healthy hosts. We present the case of an immunocompetent patient who presented with a clinical picture of VZV encephalitis with the sole precipitating factor of advanced age. We want to stress the importance of including VZV in the differential diagnosis for encephalitis in healthy elderly hosts. In patients with a clinical diagnosis of encephalitis, the presence of herpes zoster rash increases the likelihood of VZV encephalitis. However, the absence of a skin rash may not exclude the diagnosis. In general, there is an elevated risk of transient ischaemic attack and stroke associated with the diagnosis of herpes zoster infection. Early treatment is essential to prevent complications, including death.