A case of anti-glomerular basement membrane disease complicated by severe cytomegalovirus enteritis in a patient who survived after a prolonged ICU stay.

Abstract

Anti-glomerular basement membrane (GBM) disease causes rapidly progressive glomerulonephritis (RPGN) and has a high mortality rate from lung hemorrhage or infection as a side effect of immunosuppressive treatment. We report a case in which a patient with anti-GBM disease experienced severe jejunal bleeding due to cytomegalovirus (CMV) enteritis during immunosuppressive treatment. A previously healthy 74-year-old female was admitted to our hospital with severe acute kidney injury due to intrinsic kidney disease. The patient was anuric, and hemodialysis was started. The initial serum anti-GBM antibody level was elevated at 1880 U/mL. Kidney biopsy demonstrated global glomerulosclerosis and diffuse crescent formation on light microscopy. Immunofluorescence revealed focal deposition of IgG along the glomerular capillaries. The patient was diagnosed with RPGN secondary to anti-GBM disease, and oral prednisolone and double filtration plasmapheresis (DFPP) were begun. During treatment, the patient developed recurrent jejunal hemorrhage refractory to endoscopic clipping. Surgical resection of the intestine was performed to control bleeding. There were CMV-positive cells within the resected jejunum on immunohistochemistry. CMV antigens were also detected in the serum. The patient was diagnosed with CMV enteritis and treated with ganciclovir. Ultimately, the patient was discharged home without any neurologic problems on the 285th day of hospitalization. When treating severe anti-GBM antibody disease, there is a dilemma between the effectiveness and the side effects, especially infections, of immunosuppressive therapy. In this case, moderate immunosuppressive therapy with corticosteroids and DFPP without cyclophosphamide contributed to controlling the CMV enteritis and the patient's survival.