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Sepsis-associated focal necrotising glomerulonephritis due to silicon dioxide excipient?: case report A 41-year-old man developed sepsis-associated c-ANCA pauci-immune focal necrotising glomerulonephritis (PIFNGN) during treatment with aspirin/caffeine/salicylamide [Stanbacks], containing the excipient silicon dioxide. The man presented with a 3-week history of haematuria and a 2-month history of chills, fever and sweats. He also reported generalised myalgias and arthralgias, progressive leg oedema, anorexia, nausea, vomiting and dyspnoea. In the 2 months prior to admission, he had been taking OTC pain relief and anti-inflammatories including oral aspirin/ caffeine/salicylamide 650mg/32mg/200mg several times daily, which contained the excipient silicon dioxide. He had a subclavian port-a-cath that had been previously implanted for antibacterial administration following a procedure 9 months earlier. Examination revealed hypertension, anasarca, fever, an oxygen saturation of 96% and a cardiac friction rub. Multiple petechiae and follicular pustules were observed on both legs, as well as subcutaneous nodules on his face and torso and ulcerations in both axillae. Swelling and tenderness was noted on his knees, ankles and wrists. Laboratory findings revealed a creatinine level of 10.7 mg/dL, a blood urea nitrogen (BUN) level of 137 mg/dL and a WBC count of 31 670/µL with 97% neutrophils. Urinalysis showed gross haematuria with the presence of protein, dysmorphic RBC casts, WBC casts, bacteria, dysmorphic RBCs, WBCs and leucocyte esterase. His total protein excretion was 4.8g and he had a 24-hour urine creatinine clearance of 7 mL/min. Interstitial oedema and a small pleural effusion were observed on chest X-ray. A subsequent CT chest scan demonstrated a large pericardial effusion, small pleural effusions bilaterally, pretracheal adenopathy, and ground glass opacities and a nodule in his right lung. Renal ultrasound revealed mildly echogenic kidneys. Multiple infections were found on cultures from blood, urine, skin and his porta-cath tip, including Enterococcus, Stenotrophomonas maltophilia, Klebsiella and Staphylococcus aureus. Metastatic calcinosis cutis with transepidermal elimination was noted on skin biopsy. Complement levels were reduced and hepatitis C virus (HCV) antibody was positive. Serology showed c-ANCA of 1:160 and p-ANCA of