M TIONG1, A PHAM1, S WILSON1,2,3, R WALKER1,2, A CHRYSOSTOMOU1,2,4
1Alfred Health, Melbourne, Australia, 2Monash University, Melbourne, Australia, 3Baker IDI, Melbourne, Australia, 4Epworth HealthCare, Melbourne, Australia
Background: HIV associated lupus like glomerulonephritis is an uncommon but well described cause of renal disease in HIV positive individuals. There is limited data to guide treatment, but combination antiretroviral therapy (cART) and systemic corticosteroids are most common. Non-steroid based therapies, such as mycophenolate mofetil (MMF), may be desirable given background significant burden of cardiovascular and metabolic disease in the HIV population.
Case report: A 34-year-old HIV positive Caucasian male presented with recurrent episodes of fever, myalgia and macroscopic haematuria. Each episode was self-resolving, typically lasting 1-3 days. HIV was diagnosed 12 years prior and viral load was undetectable since commencing cART 5 years prior. The febrile episodes started approximately 10 years prior and typically occurred 2-3 times per year, however had increased to once every 1-2 months, which prompted his presentation. There was an associated decline in renal function with a creatinine of 120umol/L, from 90umol/L one year prior. Investigation during an acute episode showed proteinuria (uPCR 80mg/mmol) with haematuria (urinary erythrocytes > 1000 x10^6/L) of glomerular morphology. Renal biopsy showed mild focal increase in mesangial cellularity. Immunoperoxidase was positive for IgA, IgG, IgM, C3, C1q. Given his history of HIV positivity and negative SLE serology, a diagnosis of HIV associated lupus like glomerulonephritis was made. Corticosteroid treatment was discussed, however given its established role in the treatment of lupus nephritis and favourable side effect profile, MMF was also considered. The patient commenced MMF 1g orally twice a day with significant clinical improvement – he has experienced only one episode 6 months into treatment.
Conclusion: MMF may be an alternative to corticosteroids in the treatment of patients with HIV associated lupus like glomerulonephritis.
Advanced trainee in renal medicine