Introduction
Not every kidney damage due to COVID-19 is fully understood. Acute tubular injury is the lesion most frequently described in this disease. However, four cases of ANCA-Associated Vasculitis with COVID-19 with immune pauci-glomerulonephritis have recently been described.
Methods
We report the case of a patient who presented with AAV in COVID-19 and who contracted COVID-19 again after receiving immunosuppressive therapy
Results
It was a 70-year-old African woman with a history of hysterectomy for uterine myomatosis 10 years ago. She was seen in the emergency room with complaints of fever, cough, and rhinorrhea. On physical examination, Blood pressure was 120/70 mmHg, pulse 112 beats/min, temperature 40 ° C, respiratory rate 24 cycles/min, and weight 82 kg. Biologically, the blood count showed a hemoglobin level of 11.2 g / dl, hyperleukocytosis at 19,000 / mm3, the C reactive protein was elevated to 260 mg / l. Serum creatinine was normal on admission and was 12 mg / L and blood urea was 0.36 g / L. The diagnosis of COVID-19 was retained by the Sars-Cov2 reverse transcription-polymerase chain reaction (RT-PCR) assay which was positive. The chest CT scan performed without injection of contrast product showed opacities in the appearance of frosted glass in both pulmonary fields. The patient was put on hydroxychloroquine (HCQ) 600 mg/day, on azithromycin (AZT) and on dexamethasone 6 mg/j. During the hospitalization period, the patient presented an acute kidney injury (AKI) with serum creatinine at 24 mg / l then at 36 mg / l. Proteinuria was 0.6 g / day and urine sediment was active with hematuria at 20,000 elements/ml with hematic cylinders. Two weeks after diagnosis, the patient was cured of COVID-19 with 2 control PCR tests which were negative. The follow-up chest CT scan was normal. However, renal failure persisted with worsening renal impairment. The worsening of the renal insufficiency prompted us to measure the ANCA which were strongly positive at 80 IU (lab threshold 20) and were of the perinuclear-ANCA (p-ANCA) type with an anti-myeloperoxidase (MPO) specificity. Antinuclear antibody and anti-glomerular basement membrane (anti-GBM) antibody were negative. Kidney biopsy was performed and showed an aspect of crescent glomerulonephritis in the sequelar stage. The diagnosis of AAV with pauci-immune glomerulonephritis was retained. The patient was put on methylprednisone 10 mg / kg for 3 days then on prednisone 60 mg /day. Cyclophosphamide (CYC) was used as an immunosuppressant at a rate of 500 mg every 3 weeks. After one month of treatment, the patient was readmitted to the hospital for deterioration of general conditions. 48 hours later, the patient presented respiratory distress and the chest CT scan performed showed opacities in frosted glass suggestive of a Sars-Cov-2 infection. The SARS-CoV-2 RT-PCR was positive. This new contamination to SARS-CoV-2 had occurred 6 months after the first. The patient was again put on HCQ 600 mg / day, on AZT, dexamethasone, and heparin. The patient died a week later from respiratory distress.
Conclusions
The occurrence of AAV during COVID-19 may not be due a fortuitous association but triggered by infection with SARS-CoV-2. The use of immunosuppressive therapy should be discussed due to the potential risk of reactivation or recurrence of the viral infection.
No conflict of interest