AP-VAS 2012 case report: a case of ANCA-negative crescentic glomerulonephritis complicating multiple opportunistic infections in the digestive tract

Abstract

Crescentic glomerulonephritis (GN) is one of the common causes of rapidly progressive glomerulonephritis (RPGN). Pauci-immune crescentic GN is usually associated with anti-neutrophil cytoplasmic antibody (ANCA). However, patients with pauci-immune crescentic GN who lack ANCAs have recently been reported. Approximately 10-30 % of patients with pauci-immune crescentic GN lack ANCAs. The clinical characteristics of patients with ANCA-negative pauci-immune crescentic GN are not entirely the same as patients with ANCA-positive GN, and this suggests that ANCA-negative and ANCA-positive pauci-immune crescentic GN might be different disease entities. We report a patient with ANCA-negative crescentic GN complicated with multiple opportunistic infections (Candida albicans, herpes simplex virus, and Cytomegalovirus) in the digestive tract during the course of immunosuppressive therapy. After antifungal and antiviral therapies including itraconazole, valaciclovir, and ganciclovir, she recovered from multiple opportunistic infections. The occurrence of comorbid opportunistic infections during the course of immunosuppressive therapy may not be rare in the elderly. However, a case of multiple opportunistic infections limited to the digestive tract is very rare.

Keywords: ANCA-negative; Candida albicans; Colitis; Crescentic glomerulonephritis; Cytomegalovirus; Esophagitis; Herpes simplex virus; Opportunistic infection.

Fig. 1

a Light micrographs showing fibrocellular crescent formation [hematoxylin and eosin (H&E) ×400]. b Immunofluorescence microscopy showing slight positive staining for IgA in the mesangium

Fig. 2

a Gastroscopy showing multiple discrete shallow ulcers with plaques in the middle and lower esophagus.b Confirmation of Candida esophagitis by Grocott staining (×400). The fungal hyphae and spores were stained. c Herpes simplex virus infection of the esophagus, producing characteristic multinucleated cells with homogeneous ground-glass intranuclear inclusions (H&E ×400)

Fig. 3

a Gastroscopy showing punched-out ulcers in the gastroesophageal junction. b Colonoscopy revealing an annular ulcer in the ascending colon

Fig. 4

a Confirmation of Cytomegalovirus esophagitis by CMV immunohistochemistry. The intranuclear viral inclusions were stained brown (×400). b Confirmation of Cytomegalovirus colitis by CMV immunohistochemistry (×400)

Fig. 5

Clinical course after the second admission