Successful treatment of steroid-refractory double-positive ANCA and anti-GBM disease with a combination of plasma exchange and immunosuppression: A case report and literature review

Abstract

The concurrence of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and anti-glomerular basement membrane (GBM) disease, known as double-positive disease, is rare, but it occurs at a much higher frequency than expected by chance. Double-positive disease has an aggressive clinical course, with no optimal treatment strategy. Here we describe a patient with steroid-refractory double-positive disease who was treated successfully with the addition of plasma exchange (PE) and cyclophosphamide (CPA). A 78-year-old Japanese woman who was diagnosed with diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis received two cycles of pulse steroid therapy. However, her respiratory and renal condition deteriorated. She was found to be positive for both myeloperoxidase-ANCA and anti-GBM antibodies. The combination of PE and CPA improved her systemic condition. This is the first case report of a patient with steroid-refractory double-positive disease who was successfully treated with the addition of PE and CPA. The marked contrast in therapeutic response to corticosteroids alone and the addition of PE and CPA in this case strongly implies that earlier induction of combination therapy aimed at rapid removal of pathogenic autoantibodies and prevention of ongoing antibody production might improve the outcome of this life-threatening disease.

Keywords: Anti-glomerular basement membrane disease; Antineutrophil cytoplasmic antibody-associated vasculitis; Double-positive disease; Immunosuppression; Plasma exchange; Relapse.

Fig. 1

Computed tomography on arrival at our hospital showed diffusely distributed ground-glass opacities in both lung fields.

Fig. 2

Summary of the patient's clinical course.

Fig. 3

Summary of 74 double-positive cases in the published articles. ANCA, antineutrophil cytoplasmic antibody; AZP, azathioprine; CPA, cyclophosphamide; CS, corticosteroids; DAH, diffuse alveolar hemorrhage; ESRD; end-stage renal disease; GBM, glomerular basement membrane; IS, immunosuppression; MMF, mycophenolate mofetil; MPO, myeloperoxidase; MTX, methotrexate; PE, plasma exchange; PR3, proteinase 3; RIT, rituximab; RRT, renal replacement therapy; wk, week.