Dr NUHA IBRAHIM1,3, Dr STEPHEN MAY1,2,3
1East Coast New England Renal Network, Sydney, Australia, 2New England Local Health District Renal Service, , Australia , 3Tamworth Rural Referral Hospital , Tamworth, Australia
Background: COVID19-era has complicated the management of glomerulonephritis as both COVID19 infection and its vaccines have been associated with de novo disease and relapses.
Case report: We report a case of a 20-year-old Caucasian male, a diesel mechanic and a smoker who presented two-weeks after second dose of AstraZeneca vaccine with fever, cough and haemoptysis. Investigations included a CT-chest, showing pulmonary haemorrhage, positive Anti-GBM-antibody at 5.8, micro-haematuria and normal Creatinine at 75. A diagnosis of Goodpasture-disease was made and he was treated with pulsed Methylprednisolone (PM) and oral Cyclophosphamide. Plasmapheresis was considered but not given as clinically well following PM. Repeat HRCT within four-weeks showed complete resolution of haemorrhage and down-trending antibodies at 4.3. Six weeks into treatment, he developed COVID19 infection with transient macro-haematuria. Over the next month his antibody levels gradually rose to 7.7 with micro-haematuria but normal creatinine. A subsequent renal biopsy confirmed Goodpastures with 10% crescents of mixed age. Three-months into treatment, his Creatinine rose to 270 and was admitted for Plasmapheresis, PM, IV Cyclophosphamide and two doses of Rituximab. Three-months after second induction and more than 30 plasmapheresis sessions, his antibody remained positive at 2.3 with normal creatinine, ongoing micro-haematuria and suppressed CD19. He was switched to Mycophenolate with ongoing prednisolone.
Conclusions: Our patient’s refractory disease could be explained by COVID19 infection and ongoing exposure to hydrocarbons. Initial COVID19 vaccine may have played a role, but there has been no case reports associating AstraZeneca vaccine to Goodpasture-disease. Evidence on management of refractory disease is limited, but Rituximab and mycophenolate have been used in several case reports and it can take up-to 10 months for full clinical and immunological remission.
Biography:
Nephrology advanced trainee at East Coast New England Renal Network