Glomerular Disease in Temporal Association with SARS-CoV-2 Vaccination: A Series of 29 Cases.

Background: Immune responses to vaccination are a known trigger for a new onset of glomerular disease or disease flare in susceptible individuals. Mass immunization against SARS-CoV-2 in the COVID-19 pandemic provides a unique opportunity to study vaccination-associated autoimmune kidney diseases. In the recent literature, there are several patient reports demonstrating a temporal association of SARS-CoV-2 immunization and kidney diseases. Methods: Here, we present a series of 29 cases of biopsy-proven glomerular disease in patients recently vaccinated against SARS-CoV-2 and identified patients who developed a new onset of IgA nephropathy, minimal change disease, membranous nephropathy, ANCA-associated GN, collapsing glomerulopathy, or diffuse lupus nephritis diagnosed on kidney biopsies postimmunization, as well as recurrent ANCA-associated GN. This included 28 cases of de novo GN within native kidney biopsies and one disease flare in an allograft. Results: The patients with collapsing glomerulopathy were of Black descent and had two APOL1 genomic risk alleles. A brief literature review of patient reports and small series is also provided to include all reported cases to date (n=52). The incidence of induction of glomerular disease in response to SARS-CoV-2 immunization is unknown; however, there was no overall increase in incidence of glomerular disease when compared with the 2 years prior to the COVID-19 pandemic diagnosed on kidney biopsies in our practice. Conclusions: Glomerular disease to vaccination is rare, although it should be monitored as a potential adverse event.

Multicystic dysplastic kidney complicated by pyelonephritis.

PATIENT: Female, 21 FINAL DIAGNOSIS: Multicystic Dysplastic Kidney Disease complicated by pyelonephritis Symptoms: Left flank pain (CVAT) • dysuria • fever MEDICATION: Levofloxacin Clinical Procedure: Dimercaptosuccinic acid scan • voiding cystouretrogram Specialty: Nephrology. OBJECTIVE: Rare disease. BACKGROUND: Multicystic dysplastic kidney (MCDK) is a renal dysplasia characterized by the presence of multiple cysts that are non-communicating, separated by dysplastic parenchyma that consumes the renal cortex resulting in a nonfunctional kidney. MCDK has an incidence of 1: 4300 of live births and is usually unilateral, most commonly occurring in the left kidney. Simple MCDK is defined as unilateral dysplasia with a normal contralateral kidney but with compensatory hypertrophy of the contralateral kidney, and no associated genitourinary anomalies. CASE REPORT: A 21 year old Hispanic American female, presented with intermittent, sharp, severe left flank pain, fever and dysuria for two days but had gradually worsened within the last 24 hours prior to presentation. Previous history of multicystic dysplastic kidney, diagnosed four years ago. No pertinent physical examination findings except left costovertebral angle tenderness (CVAT). Urinalysis findings were positive for infection and urine culture grew pan sensitive Escherichia coli. A CT scan of abdominal and pelvis without contrast revealed a normal right kidney and left kidney had multiple non-communicating dilated cystic spaces, but no hydronephrosis, left ureteropelvic junction obstruction and finding were consistent with multicystic dysplastic kidney and also noted perinephric stranding. CONCLUSIONS: VUR is the most common renal abnormality in patients with MCDK, occurring in about 25% of contralateral kidney. Infections involving the MCDK are rare. In fact, cases of infections such as pyelonephritis or an infected renal cyst of MCDK are almost non-existent in the current literature. This patient presented with findings consistent with MCDK complicated by pyelonephritis.

Dural arteriovenous fistula discovered in patient presenting with recent head trauma.

UNLABELLED: Patient Male, 32 FINAL DIAGNOSIS: Dural arterio-venous fistula Symptoms: Eye redness • post-trauma headache • tinnitus MEDICATION: - Clinical Procedure: Fistula embolization Specialty: Neurology. OBJECTIVE: Mistake in diagnosis. BACKGROUND: A dural arteriovenous fistula (DAVF), is an abnormal direct connection (fistula) between a meningeal artery and a meningeal vein or dural venous sinus. The pathogenesis of DAVF still remains unclear. Sinus thrombosis, head trauma, chronic central nervous system, hypercoagulable state, surgery, and hormonal influence are the pre-disposing factors that initiate this disease. The symptoms experienced by the patient will depend on the location of the fistula. CASE REPORT: Thirty-two year old Hispanic male who presented one day after a rear ended motor vehicle collision (MVC) with a severe throbbing headache in the left parietal region, left eye redness but no retro-orbital pain and tinnitus in the left ear. He was initially misdiagnosed to have a carotid-cavernous fistula but upon cerebral angiogram was actually diagnosed with a dural arterio-venous fistula in the posterior fossa venous system followed by successful embolization of the fistula. CONCLUSIONS: A cerebral angiography is the gold standard for detection and characterization of a DAVF and will distinguish it from a CCF. Endovascular surgery involves a catheter-based technique for embolization of the lumen of arteries feeding the DAVF, or directly into the vein draining the DAVF. It is very important to recognize the typical findings of patients presenting with a DAVF then quickly proceeding with a cerebral angiogram to determine the exact location of the fistula and the appropriate treatment plan. By diagnosing and treating a DAVF as early as possible, the associated fatal complications can be averted.

Pneumococcal meningitis in a young adult female with common variable immunodeficiency.

PATIENT: Female, 22 FINAL DIAGNOSIS: Pneumococcal meningitis Symptoms: Fever • headache • neck stiffness • nuchal rigidity • photophobia MEDICATION: Ceftriaxone Clinical Procedure: - Specialty: Neurology. OBJECTIVE: Rare disease. BACKGROUND: Common variable immunodeficiency (CVID) is a primary immunodeficiency associated with hypogammaglobulinemia and other various clinical manifestations. It is a rare disease with a prevalence of CVID is approximately 1: 50,000-200,000. Clinical manifestations of CVID include recurrent bacterial infections, autoimmune, gastrointestinal, lymphoproliferative, granulomatous, and malignancy. CASE REPORT: Twenty-two year-old Hispanic female presented with a throbbing headache, nuchal rigidity, photophobia and a high grade fever. Lumbar puncture with CSF assessment revealed a turbid fluid with WBC of 6937 per uL, polymorphnuclear cells of 81%, protein 248 mg/dL, glucose <3 mg/Dl. CSF antigens were positive for Streptococcus pneumonia and CSF culture grew pansensitive Strepococcus pneumonia. Immunoglobin (Ig) levels of IgA, IgE, IgG and IgM were all decreased. Absolute cell counts of CD3, CD4 and CD8 were all low. Bone marrow biopsy was normocellular. Excisional lymph node biopsy revealed lymph nodes with reactive follicular hyperplasia. Common variable immunodeficiency disease (CVID) was diagnosed based on exclusion. IVIG therapy was given and patient received a two-week course of ceftriaxone. CONCLUSIONS: THE DIAGNOSIS OF CVID IS MADE BASED ON THE FOLLOWING CRITERIA: 1) Marked decrease of IgG and at least one of the IgM or IgA isotypes. 2) The onset of immunodeficiency at greater than 2 years old. 3) Absence of isohemagglutinins and/or poor response to vaccines 4) Exclusion of other defined causes of hypogammaglobulinemia. A definite diagnosis is often late because it is wrongly assumed that primary immunodeficiencies are extremely rare, hence many patients are already seriously ill at the time of presentation.