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Critical Care |

ANCA Positivity and a Red Herring

Gina Huss, MD; Matthew Cossack, MD; Javeria Syed, MD; Muhammad Sarfraz Nawaz, MBBS; Pranathi Sundaragiri, MD; Agnes Colanta, MD; Sunil Jagadesh, MBBS; Khalid Bashir, MD; Renuga Vivekanandan, MD
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Creighton University, Omaha, NE


Chest. 2015;148(4_MeetingAbstracts):282A. doi:10.1378/chest.2278736
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Abstract

SESSION TITLE: Critical Care Student/Resident Case Report Posters III

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Seroconversion from HIV-1 to AIDS often presents with malaise, fatigue, fever, lymphadenopathy and weight loss and can take up to 10-20 years. We describe a case of nephrotic syndrome secondary to HIV immune complex kidney (HIVICK) disease and newly-diagnosed AIDS in the setting of positive c-ANCA serology.

CASE PRESENTATION: A 38 year-old African-American male who emigrated from Africa 10 years ago presented with worsening lower-extremity edema, mild hemoptysis and renal impairment. Past medical history included hypertension, latent TB and anemia. He denied IV drug use and was married with one child. Exam revealed edema to the waist and white-cell count 4,100 /mm3, platelets 119,000/dL, hemoglobin 9.9 g/dL, creatinine 2.3, urine protein 6.95 g/24h, positive c-ANCA, and low C3. Renal biopsy revealed basement membrane thickening with subsegmental, subepithelial, mesangial and capillary electron-dense deposits consistent with proliferative glomerulonephritis. With worsening blood counts, HIV was tested and ELISA was positive. Diagnosis was confirmed with positive western and CD4 count 16 cells/mm3. Renal function and edema improved with a loop diuretic. With negative HLA-B*5701, he was started on abacavir-dolutegravir-lamivudine.

DISCUSSION: ANCA positivity has been found secondary to HIV infection in up to 20-83% of cases1. Several forms of HIV associated renal disease exist e.g., HIV associated nephropathy (HIVAN), more commonly seen in advanced disease and black race. HIVICK is another form and is seen in advanced disease and black race as well, but antiretroviral therapy (ART) is not as beneficial2. Screening for HLA-B*5701 allele is important as one-pill ART regimens include abacavir. This antiretroviral has been associated with hypersensitivity reactions ranging from rash and fever to death in those who are HLA-B*5701 positive3. Abacavir use is reasonable in patients with renal impairment since dose adjustment is not necessary. However, a declining eGFR may require different ART regimens.

CONCLUSIONS: AIDS can present as nephrotic syndrome in the form of HIVICK. ANCA positivity should not prompt the clinician to empirically start cytotoxic drugs as this can be deleterious for patients with HIV. One must have a high index of suspicion for HIV, even when risk factors are not apparent. Treatment regimens will differ for an HIV patient with concomitant renal impairment.

Reference #1: Jansen TL, et al. ANCA seropositivity in HIV: a serological pitfall. Neth J Med 2005:63(7):270-274.

Reference #2: Foy MC, et. al., Comparison of risk factors and outcomes in HIV immune complex kidney disease and HIV-associated nephropathy. Clin J Am Soc Nephrol. 2013;8(9):1524.

Reference #3: Mallal S, et al., HLA-B*5701 Screening for Hypersensitivity to Abacavir. N Engl J Med. 2008: 358:568-79.

DISCLOSURE: The following authors have nothing to disclose: Gina Huss, Matthew Cossack, Javeria Syed, Muhammad Sarfraz Nawaz, Pranathi Sundaragiri, Agnes Colanta, Sunil Jagadesh, Khalid Bashir, Renuga Vivekanandan

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