ond discharge . Subsequently , the patient was being seen by a rheumatology clinic at another academic center , where he was admitted for fever in the setting of immunosuppression and bilateral lower extremity weakness . Repeat biopsy done
FIGURE 1 A . B .
C . D .
E . F .
G . H .
Results of Renal Biopsy . A . Overview B . Crescents C . Crescent with fibrinoid necrosis D . Fibrocellular crescent E . Artery F . IgG G . G . Fibrinogen . H . Electron microscopy shows no deposits .
at the second institution to confirm the diagnosis showed persistent ANCA-associated disease , with diffuse moderate tubular injury and moderate arteriosclerosis and arteriolar hyalinosis . A gastrocnemius muscle biopsy was also performed ,
which confirmed systemic medium vessel vasculitis . Other investigations had been unremarkable for any identifiable source of infection .
Extensive workup was repeated during a subsequent hospital stay approximately six months after the initial insult and showed persistently low eGFR (< 15 mL / min / 1.73m2 ), elevated creatinine ( 3-5 mg / dL , status on dialysis ), ongoing hematuria ( large blood , > 100 RBCs / high power field ), and proteinuria (> 500 mg / dL , spot ).
Due to lack of significant response and drug reaction to cyclophosphamide , the patient was switched to rituximab with ongoing dialysis . He is currently on the kidney transplant waiting list .
DISCUSSION
Lyme disease is caused by the spirochete Borrelia Burgdorferi , a microbe that is spread to humans via the Ixodes tick in the northeastern United States . Usual clinical presentation of acute Lyme disease includes erythema migrans , fever , chills , headache , fatigue , and myalgias . Manifestations of disseminated infection include heart block caused by myocarditis , nerve palsies , large joint migratory polyarthritis , and encephalopathy .
Vasculitis precipitated by or associated with Lyme disease is exceedingly rare and likely underrecognized . Lyme-induced renal failure has been ascribed to membranoproliferative glomerulonephritis 1 – 4 with IgG / C3 renal deposition , minimal change disease , 5 , 6 and IgA nephropathy 7 secondary to acute or chronic Lyme disease . These cases report varying levels of renal injury and improvement with treatment , which usually includes some combination of antimicrobials and steroids . Responses range from complete resolution of renal symptoms to lifelong dialysis dependency .
ANCA-associated vasculitis is an autoimmune disease affecting small blood vessels in the body . ANCA formation can be triggered by a multitude of insults , including drugs , environmental exposures , and infection . A number of different bacterial species have been linked to ANCA formation , 8 but to our knowledge , there have
West Virginia Medical Journal • December 2024 • 15