#5034 ANCA ASSOCIATED VASCULITIS AFTER COVID-19
Authors: Rihem Dahmane , Azzabi Awatef , Boukadida Raja , Mrabet Sanda , Guedri Yosra , Wissal Sahtout , Zellama Dorsaf 
Published: June 2023

Abstract

Background and Aims
ANCA associated vasculitis (AAV) is a group of systemic autoimmune diseases characterized by inflammation of small and medium sized vessels. The three main types of AAV are granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). Similar pathways are involved mechanisms of disease involving COVID-19 and ANCA-associated vasculitis. For instance, neutrophil extracellular traps (NETs) are induced in both entities.

Method
We describe 3 cases reports of patients with ANCA associated vasculitis after COVID19.

Results
Case 1: A 46-year-old female patient was hospitalized in intensive care unit for COVID19 pneumonia. She has fever, cough and dyspnea. A few days before, the SARS-CoV-2 polymerase chain reaction(PCR) was positive on nasopharyngeal swab. She received high flu nasal canula. She presented a pneumo-renal syndrome with intra-alveolar hemorrhage and acute kidney injury. Chest scanner shows lesions on bilateral lung parenchyma, and an acute kidney injury (AKI) on admission. Urinalysis revealed an active sediment with dysmorphic erythrocytes and signifcant proteinuria. Renal function gradually deteriorated. So intermittent hemodialysis treatment was initiated. Serological evaluation showed negative antinuclear antibody, and anti-dsDNA, normal serum complements, and an elevated MPO. In kidney biopsy, pauci-immune necrotizing GN with cellular crescents was detected. The patient received pulse dose corticosteroids and subsequently, she was transitioned to oral prednisone. She underwent 2 sessions of plasmapheresis, which were stopped in the absence of confirmation of pulmonary involvement. She received cyclophosphamide during the hospitalization. While hematuria and proteinuria were persistant in the most recent urinalysis, the sCr level decreased to 159 µmol/L. In addition, she developed adrenal insufficiency after stopping corticosteroid therapy, requiring her to be put on Cortef.
Case 2: A 63-year-old female patient with past medical history of hypertension, was hospitalized in intensive care unit for dyspnea and hemoptysis. A few months before, the SARS-CoV-2 polymerase chain reaction(PCR) was positive on nasopharyngeal swab. She received high flu nasal canula (HFNC). At this moment, she had acute kidney injury with a sCr level of 165µmol/L that was not explored. Currently she presented a pneumo-renal syndrome with a rapidly progressive glomerulonephritis and intra-alveolar hemorrhage. Renal function gradually deteriorated and peak sCr level of 308µmol/L. Chest scanner shows ground glass lesions of bilateral lung parenchyma, and hemoglobin at 4.9 g/dL. Urinalysis revealed an active sediment with dysmorphic erythrocytes and signifcant proteinuria. So intermittent hemodialysis treatment was initiated. The patient received pulse dose corticosteroids and subsequently, she was transitioned to oral prednisone. She received cyclophosphamide during the hospitalization. Serological evaluation showed negative antinuclear antibody, and anti-dsDNA, normal serum complements, and an elevated MPO. She underwent 6 sessions of plasmapheresis, for intra-alveolar hemorrhage. There was an improvement in respiratory and renal function
Case 3: 57 years old, with a history of functional colopathy, covid infection 1 month before her hospitalization in nephrology department for kidney injury. Currently she presented a pneumo-renal syndrome with a rapidly progressive glomerulonephritis and intra-alveolar hemorrhage. Urinalysis revealed an active sediment with dysmorphic erythrocytes and signifcant proteinuria. Serological evaluation showed negative antinuclear antibody, and anti-dsDNA, normal serum complements, an elevated MPO and positive anti GBM. She was treated with plasmapheresis and cyclophosphamide.

Conclusion
SARS-CoV-2 infection can be a 'trigger factor' for vasculitis. ANCA-associated vasculitis should be kept in mind in patients who develop acute kidney injury after COVID-19.