Two patients, two viruses and multiple sites of injury in the kidney
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NEPHROLOGY PICTURE
Two patients, two viruses and multiple sites of injury in the kidney Rezzan Eren Sadioglu1 · Sahin Eyupoglu1 · Saba Kiremitci2 · Serhat Birengel3 · Kenan Keven1 Received: 22 April 2020 / Accepted: 11 August 2020 © Italian Society of Nephrology 2020
Abstract Viral nephropathy is a term defines glomerular, tubular and/or vascular injury in kidney caused by viruses itself or virusinduced immune mechanisms. It is difficult to prove causality between the renal disease and the viral infection, however, renal biopsy findings can help in this regard. Several viruses such as hepatitis B and C, Human immun deficiciency virus (HIV), Hantavirus, Cytomegalovirus (CMV), an recently Coronavirus are shown to affect the kidney. Treatment of viral nephropathies are unique regarding the diagnosis which can be made only with renal biopsy in most of the situations. We present two patients presented with acute kidney injury and thrombocytopenia caused by different viruses (Hantavirus and HIV) that affect multiple areas in kidney that revealed with kidney biopsy. Supportive treatment in the patient with Hantavirus nephropathy and HIV treatment along with eculizumab and supportive treatment in the patient with HIVAN were successfully implemented. Keywords Hantavirus · HIVAN · Thrombotic microangiopathy · Acute kidney injury · Viral nephropathy
Case presentations We report two patients who presented with acute kidney injury (AKI) and thrombocytopenia caused by different viruses, revealed through kidney biopsies, that affect multiple compartments in the kidney.
Case 1 A 34-year-old male without any comorbidities presented with fever (39 °C), fatigue and myalgias that had been going on for a week. He reported possible contact with mice in his office. Physical examination was unremarkable. On first admission, blood chemistry revealed mild hepatic enzyme elevation and normal creatinine level [alkaline phosphatase * Rezzan Eren Sadioglu [email protected] 1
Department of Nephrology, Ankara University School of Medicine, Talatpasa Bulvari No: 82, 06510 Altindag, Ankara, Türkiye
2
Department of Pathology, Ankara University School of Medicine, Ankara, Turkey
3
Department of Infectious Disease and Clinic Microbiology, Ankara University School of Medicine, Ankara, Turkey
(ALP), 210 U/L; gamma-glutamyl transpeptidase (GGT), 200 U/L; alanine aminotransferase (ALT), 30 U/L; aspartate aminotransferase (AST), 69 U/L; lactate dehydrogenase (LDH), 354 U/L; direct bilirubin, 0.18 mg/dL; indirect bilirubin, 0.53 mg/dL; creatinine 0.97 mg/dL]. His blood count showed thrombocytopenia (30 × 109/L) without any schistocytes on the peripheral blood smear. His creatinine level increased to 2.29 mg/dL in 4 days along with nephrotic range proteinuria (spot urine protein/creatinine, 5,000 mg/g) and hypoalbuminemia (serum albumin, 2.9 g/dL). Viral serologies were sent for hepatitis A, B, and C, HIV, CMV, and Leptospirosis, all coming back negative. ADAMTS 13 activity was 90%, so thrombotic thrombocytopenic purpura (TTP
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