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27 May 2020 : Case report  Spain

Membranoproliferative Glomerulonephritis and Mixed Cryoglobulinemia as a Form of Presentation of Visceral Leishmaniasis

Challenging differential diagnosis, Diagnostic / therapeutic accidents, Rare coexistence of disease or pathology

Maite Padrón Romero1ABDEFG*, Mercedes M. Acevedo Ribó1ABDF, Francisco Javier Ahijado Hormigos1ABDEFG, Francisco Díaz Crespo2B, Laura Cueto Bravo1F, Cristina Herraiz Corredor1F, María Ángeles Fernández Rojo1F, Rafael Díaz-Tejeiro Izquierdo1AG

DOI: 10.12659/AJCR.921445

Am J Case Rep 2020; 21:e921445

Abstract

BACKGROUND: Visceral leishmaniasis (VL) is an endemic systemic disease in the Mediterranean countries, including Spain. This vector-borne infection can present with several clinical presentations, from asymptomatic to severe forms. Renal impairment is frequently described in VL but is usually mild and related to interstitial nephritis, being that glomerular involvement is rarely found.

CASE REPORT: We describe a case of a 69-year-old Spanish male presenting with subacute renal failure due to membranoproliferative glomerulonephritis and mixed cryoglobulinemia accompanied by other autoimmune features (hypocomplementemia, antinuclear and antiDNA antibodies). No hepatosplenomegaly was found with abdominal ultrasound. Hepatotropic viruses and human immunodeficiency virus serological markers were negatives. We initially suspect the presence of an autoimmune disease and the patient was treated with steroids without improvement. After an extensive study including renal and bone marrow biopsy, a correct diagnosis of visceral leishmaniasis was made, and treatment with liposomal amphotericin B was initiated, achieving renal function recovery and normalization of immunological manifestations.

CONCLUSIONS: Renal involvement can be an important feature of VL and it might be associated with increased morbidity and mortality. The association between mixed cryoglobulinemia and renal involvement in VL have rarely been described. VL is frequently associated with diverse autoimmune manifestations and it can be initially misdiagnosed, which could lead to fatal consequences. The role of the immune system in the formation of cryoglobulins are discussed. In our case, an autoimmune disease was initially suspected, and starting treatment with steroids pulses was initiated. However, the presence of mixed cryoglobulinemia in this patient who was hepatitis C serological marker negative and who had poor renal function recovery after immunosuppressive treatment made us suspect other pathologies. The presence of cryoglobulinemia with renal disease in endemic areas of Leishmania should make us exclude this infection before starting immunosuppressive treatment.

Keywords: cryoglobulinemia, Glomerulonephritis, Membranoproliferative, Leishmaniasis, Visceral, Aged, amphotericin B, Antiprotozoal Agents, Biopsy, Leishmania, renal insufficiency, Urine

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923