Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
infection triggers elevated levels of circulating
cytokines and immune-cell hyperactivation, called a
cytokine storm, which leads to dysregulated immune response not only towards the pathogen itself but also contributes to cellular,
vascular injury and multiorgan dysfunction. The
cytokine-induced endothelial inflammation and vascular pathology of
COVID-19 is well reported in post-mortem biopsies and several cases reporting small, medium and large vessel micro/macro thrombotic events and
vasculitis in multiple organs. So far, few cases have been reported with newly diagnosed
antineutrophil cytoplasmic antibodies (
ANCA)-associated vasculitis at the time of acute
COVID-19 infection. The exact pathophysiology of SARS-CoV-2 and
ANCA-associated vasculitis continues to be studied and reviewed. Here we report a case of a 60-year-old female who presented to our institution with sudden onset of
shortness of breath and
hemoptysis. A detailed history revealed a recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
infection. Labs showed elevated serum
creatinine, urine analysis with large blood and nephrotic range
proteinuria. CT chest was remarkable for abnormal appearance of the parenchyma bilaterally compatible with a
crazy paving pattern, suggesting
pulmonary alveolar proteinosis versus diffuse alveolar
hemorrhage.
Vasculitis was suspected and the patient was started on IV
corticosteroids and
plasmapheresis. Diagnostic workup was positive for
antineutrophil cytoplasmic antibodies-
myeloperoxidase (
ANCA-MPO), anti-Sjögren's syndrome-related
antigen A
autoantibodies (anti-SS-A) and antinuclear
antibodies (ANA). Renal biopsy confirmed focal segmental necrotizing, crescentic and sclerosing
glomerulonephritis, pauci-immune type, anti-MPO antibody/
P-ANCA associated. A diagnosis of
microscopic polyangiitis was made and she was started on
rituximab immunosuppressive therapy following which she showed clinical improvement. In this document, we present a unique case of
microscopic polyangiitis possibly induced by
SARS-CoV-2 infection confirmed by renal biopsy and clinical presentation. In the current setting of a global pandemic, we strongly recommend that
vasculitis be high on the differential diagnosis in patients who are currently infected or had been infected with SARS-CoV-2 and present with
acute kidney injury (AKI).