PDF(Pubmed)
Abstract：
The coronavirus disease 2019 has been demonstrated to be a trigger for multiple immune-mediated diseases, such as antineutrophil cytoplasmic antibody-associated vasculitis. Associated vasculitis consists of rare autoimmune disorders that predominantly affect small vessels, leading to endothelial injury and tissue damage. We present a case of a newly diagnosed microscopic polyangiitis temporally associated with coronavirus disease 2019 infection in a previously healthy woman and a literature review. A 66-year-old female presented to the Emergency Room with fever, edema on her legs, productive cough, dyspnea, and hemoptysis. A chest computerized tomography scan revealed bilateral diffuse alveolar opacities with the appearance of diffuse alveolar hemorrhage. Blood analysis revealed a moderate normocytic, normochromic anemia with a hemoglobin of 6.6 g/dL, platelet count of 347 k/dL, leucocytes of 12,000/dL, a creatinine of 3.91 mg/dL (basal Cr: 0.9 mg/dL), and a Blood Urine Nnitrogen of 78 mg/dL. A urine sediment demonstrated glomerular hematuria, with mixed shapes of red blood cells. She was admitted to the intensive care unit and a bedside bronchoscopy revealed progressive bleeding with a bronchioalveolar lavage positive for diffuse alveolar hemorrhage. Given the critical involvement of the lungs and kidney function, the diagnostic approach revealed a positive p-anti-neutrophil cytoplasmic antibody on immunofluorescence and an anti-MPO (myeloperoxidase) level of 124.6 IU/mL. A renal biopsy demonstrated pauciimmune focal and segmental glomerulosclerosis. A diagnosis of microscopic polyangiitis triggered by severe acute respiratory syndrome coronavirus 2 infection was made, and immediate treatment with pulse-dose steroids and cyclophosphamide was initiated. The patient needed renal replacement therapy and was discharged for follow-up with nephrology and rheumatology services. The diagnostic approach of associated vasculitis can be more challenging in the coronavirus disease era. Atypical features in the pulmonary imaging and a rapid deterioration of the renal function should arise the clinical suspicion of the presence of an added condition to the coronavirus disease infection. Autoimmune conditions such as associated vasculitis should be evaluated even in the absence of previous autoimmune history. Prompt diagnosis and treatments must be prioritized to avoid end-organ definite damage. Further, larger and more collaborative studies are needed to confirm the potential role of coronavirus disease 2019 as a trigger of associated vasculitis.
摘要：
2019年冠状病毒病已被证明是多种免疫介导疾病的触发因素，如抗中性粒细胞胞浆抗体相关性血管炎。相关血管炎包括罕见的自身免疫性疾病，主要影响小血管，导致内皮损伤和组织损伤。我们介绍了一例新诊断的显微镜下多血管炎，该病例在先前健康的女性中与2019年冠状病毒病感染暂时相关，并进行了文献综述。一名66岁的女性因发烧出现在急诊室，她腿上有水肿,生产性咳嗽,呼吸困难,还有咯血.胸部计算机断层扫描显示双侧弥漫性肺泡混浊，伴有弥漫性肺泡出血。血液分析显示中度正常细胞，血红蛋白为6.6g/dL的正常色素性贫血，血小板计数为347k/dL，白细胞12,000/dL，肌酐为3.91mg/dL（基础Cr：0.9mg/dL），血尿氮为78mg/dL。尿沉渣显示肾小球性血尿，红细胞的混合形状。她被送进重症监护病房，床旁支气管镜检查显示进行性出血，支气管肺泡灌洗呈弥漫性肺泡出血阳性。鉴于肺和肾功能严重受累，诊断方法显示免疫荧光检测P-抗中性粒细胞胞浆抗体阳性,抗MPO(髓过氧化物酶)水平为124.6IU/mL.肾活检显示缺乏免疫局灶性和节段性肾小球硬化。诊断为由严重急性呼吸综合征冠状病毒2感染引发的显微镜下多血管炎，并立即开始脉冲剂量类固醇和环磷酰胺治疗。患者需要肾脏替代治疗，并出院接受肾脏科和风湿病服务的随访。在冠状病毒疾病时代，相关血管炎的诊断方法可能更具挑战性。肺部成像中的非典型特征和肾功能的快速恶化应该引起临床怀疑，即冠状病毒疾病感染存在附加条件。即使没有先前的自身免疫性病史，也应评估自身免疫性疾病，例如相关的血管炎。必须优先考虑及时的诊断和治疗，以避免最终器官的明确损害。Further,需要更大规模和更多的合作研究来确认2019年冠状病毒病作为相关血管炎触发因素的潜在作用.
