Membranous nephropathy with lupus-like pattern in a patient with HIV and multicentric Castleman disease

Abstract

Introduction: Nephrotic syndrome in patients with HIV infection has multiple aetiologies, including HIV associated nephropathy (HIVAN), HIV associated immune-complex kidney disease (HIVICK), drugs associated kidney toxicity and acute kidney injury. Kidney biopsy is key to differentiate among diverse aetiologies of renal commitment.

Purpose: The aim of the present case is to describe an unusual cause of nephrotic syndrome in HIV-positive patients and the usefulness of renal biopsy for its proper diagnosis and treatment.

Case presentation: Masculine of 32 years with prior history of HIV infection undergoing treatment with tenofovir, emtricitabine and efavirenz, along with Kaposi’s sarcoma with skin involvement who presents at the emergency department with oedematous syndrome and neck lymph node enlargement. Multicentric Castleman disease was diagnosed upon clinical, biochemical, and histopathological findings. The patient did not present with stigmata of autoimmune disease and had a presenting serum creatinine of 3.04 mg/dl (baseline serum creatinine of 0.88 mg/dl). Other laboratory investigations included an urinalysis with microscopic haematuria and proteinuria, a renal and urinary tract ultrasound without gross alterations and a 24-hour urine recollection with 16.5 grams of proteinuria. He also had hypoalbuminemia (1.6 g/dl). Altogether, criteria for nephrotic syndrome were fulfilled.

We also found normal serum complement, serum protein electrophoresis with polyclonal hypergammaglobulinemia and an autoimmune panel with low positive (1 in 80 dilutions) antinuclear antibodies with cytoplasmatic pattern along with proteinase-3 positive antibodies. Myeloperoxidase antibodies were negative. Upon these results we obtained a kidney biopsy compatible with membranous glomerulonephritis, with immunofluorescence compatible with a full-house pattern. A diagnosis of membranous nephropathy with lupus-like pattern with suspected secondary cause was made, in relation to haematological disease associated with HIV infection. Management with water restriction, prophylactic anticoagulation, antagonist receptor blocker (ARB) and statin, was indicated, without changes in combination antiretroviral therapy.

Discussion and conclusion: There is a rare association between HIV infection and Castleman multicentric disease with membranous glomerulopathy and lupus-like pattern as an immunological epiphenomenon. Thus, it is of paramount importance to evaluate differential diagnosis in patients presenting with HIV infection and nephrotic syndrome.