Antineutrophil cytoplasmic antibody (ANCA) vasculitis with glomerulonephritis in COVID-19

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it inflicts, coronavirus disease 2019 (COVID-19), has become a global pandemic in 2020 To date, only one case of ANCA associated vasculitis (AAV) with COVID-19 has been reported from Iran We describe the first two cases of AAV and glomerulonephritis in the United States Case Description: Case one: 64 year old African American male with a distant (> 10years) history of cryptogenic organizing pneumonia presented to the hospital with hypoxic respiratory failure secondary to COVID19 He had an acute kidney injury(AKI) with elevated creatinine(Cr) of 7 87mg/dL Urinalysis revealed active sediment with 55 RBC/ hpf, 65 WBC/hpf, and nephrotic range proteinuria: 5 gm/gm of creatinine He was initiated on renal replacement therapy and received convalescent plasma along with Tocilizumab for the treatment of COVID-19 Serologic testing revealed a positive perinuclear (p)-ANCA (1:320), myeloperoxidase (32 5) Kidney biopsy was consistent with a pauci immune glomerulonephritis;cellular crescent present in 40% of glomeruli He received pulse dose steroids and Rituximab The patient had a good clinical response and was able to discontinue hemodialysis and serum Cr decreased to 3 5mg/dL Case Two: 46 year old South Asian male presented with rash from leukocytoclastic vasculitis and was diagnosed with COVID-19 He had an AKI, serum Cr peaked at 4 0mg/dL with proteinuria, leukocyturia, and microhematuria on urinalysis Cytoplasmic(c)-ANCA and proteinase-3(PR-3) were positive A kidney biopsy was performed which revealed a necrotizing glomerulonephritis He was treated with steroids and Rituximab with a positive response, Cr decreased to 2 0mg/dL Discussion: It is now well known that SARS-CoV-2 affects organs outside of the respiratory system, with the kidneys being a usual target The most commonly reported presentation of COVID-19 and the kidneys is AKI, the etiology of which is predominantly acute tubular necrosis (ATN) Collapsing GN is by far the most described glomerular lesion Clinicians should be aware of AAV with GN as another potential pathology, and concurrent use of immunosuppression with treatment of infection, can lead to favorable clinical outcomes