Introduction
Microscopic polyangiitis MPA is an idiopathic autoimmune disease characterized by a systemic vasculitis that predominantly affects the small- caliber blood vessels, particulary involving the kidney, lungs, nerves, skin and joints. The assocaition between renal thrombotic microangiopathy , ANCA vasculitis and covid 19 infection is rare and new.
Methods
We report a case of a renal thrombotic microangiopathy in an ANCA-associated vasculitis with Covid 19 infection.
Results
We present a case of a 49-year old man, presented to the emergency department with complaints of dyspnea, hemoptysis, epistaxis and an hypertensive encephalopathy. He was intubated due to worsening respiratory failure. Two thoracic scan revealed ground glass opacities suggesting a SARS-Cov2 infection and RT-PCR COVID-19 positive from nasopharyngeal swab . Laboratory studies revealed the following: hemoglobin5,3g/dL prompting transfusion and creatinine1200 umol/dL requiring dialysis. He was extubated after 14days then was transferred to nephrology department because of renal failure. On physical exam, he appeared confused,disoriented to place and time, euvolemic and afebrile, with a blood pressure of 110/70 mmHg. The rest of his physical examination was unremarkable. Complete blood test on admission revealed: hemoglobin 7.6 g/dL, CRP 88mg/l ,creatinine 700 µmol/L, blood glucose 0,7 g/ L. The urine dipstick test showed microscopic hematuria and proteinuria. Vasculitis workup was remarkable for a positive p-antineutrophil cytoplasmic antibody (p-ANCA), positive myeloperoxidase- (MPO-) ANCA of >11 antibody index. Results were negative for anti-glomerular basement membrane antibodies and anti-proteinase-3 antibody. CT scan was performed showing the same lesions of ground glass opacities as the two previous scans. Bronchoalveolar lavage wasn't done due to covid situation. Furthermore, in front of the neurologic manifestations, a cerebral MRI was done and showed White matter lesions suggesting the diagnosis of cerebral vasculitis, Central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM), and filled sinus cavities. The lumbar puncture’s results were normal. The kidney biopsy was showed vascular involvement and fibrous crescent . Immunofluorescence was negative. the fundus examination revealed an hypertensive choroidopathy. A methylprednisolone 1 gram IV for 5 days ,switched to oral prednisone 1mg/kg/j and cyclophosphamide 0.5g/kg were prescribed. In addition, he received one round of plasma exchange for pulmonary hemorrhage. 20 days after receiving this treatment, the patient developed fever and dyspnea. We made an infectious investigation: the urine culture positive to Candida, Hemocultures done, RT-PCR COVID-119 was negative, Thoracic scan revealed a bronchoalveolar hemorragies .He received broad spectrum antiobiotics ( Imipenem, amikacin, Fluconazole, Colistin and teincoplanin) but he died of sepsis two days later.
Conclusions
In summary, ANCA-associated GN and thrombotic microangiopathy can be associated with COVID-19. In a relatively short period of time, several case reports have begun to shed some light on potential mechanisms of kidney injury associated with COVID-19.Like the majority of kidney diseases, the mechanisms are most likely to be multifactorial
No conflict of interest