[An autopsy case of microscopic polyangiitis complicated with pulmonary aspergilloma and cytomegalovirus pneumonia].
A 71-year-old man was admitted to our hospital because of fever and rapidly progressive renal insufficiency over a month. He had depression and Alzheimer's disease as complications. On admission, his serum creatinine was 5.4 mg/dL, and the serum CRP and MPO-ANCA were 18.2 mg/dL and 285 EU, respectively. A computed tomographic chest scan showed pericardiac effusion and fibrosis in both lower lung fields. Although microscopic polyangiitis(MPA)was inferred from a positive MPO-ANCA, renal biopsy could not be carried out. The initial therapy was started with pulse methylprednisolone therapy, followed by oral administration of prednisolone at the dose of 1 mg/kg(60 mg/day). As a result, his fever and inflammatory findings disappeared, and renal insufficiency was ameliorated with a smooth recovery and the pericardial effusion was markedly diminished. However, on the 18th hospital day, chest radiography revealed a nodular shadow in the right lung. Fungus infection was suspected because his serum beta-D-glucan level was extremely high (above 999 pg/mL). Mikafungin, therefore, was started at a dose of 75 mg/day and then, the dose was increased up to 300 mg/day. Nevertheless, he finally died of respiratory failure on the 26th hospital day. The autopsy findings revealed a cavity of 4.0 x 3.0 x 3.0 centimeters in size in the upper lobe of the right lung. There was a great number of fungal threads with a septal wall branched in a Y-shaped figure around the cavity, thus indicating pulmonary aspergilloma. Intranuclear inclusion bodies staining positive for cytomegalovirus were observed in all the lung fields, suggestive of a cytomegalovirus infection. In the kidney, a cellular crescent formation was noted in the majority of glomeruli showing crescentic glomeluronephritis, compatible with MPA.
Kuboshima
Shingo
S
Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.
Tsuruoka
Kayori
K
Shirai
Sayuri
S
Sasaki
Hiroyo
H
Sakurada
Tsutomu
T
Miura
Hiroshi
H
Okabayashi
Jun
J
Konno
Yusuke
Y
Shima
Yoshinori
Y
Yasuda
Takashi
T
Sato
Takeo
T
Kimura
Kenjiro
K
D000368:Aged; D000544:Alzheimer Disease / Q000150:complications; D019268:Antibodies, Antineutrophil Cytoplasmic; D001228:Aspergillosis / Q000209:etiology* / Q000473:pathology; D003586:Cytomegalovirus Infections / Q000209:etiology* / Q000473:pathology; D005921:Glomerulonephritis / Q000150:complications / Q000473:pathology; D006801:Humans; D008172:Lung Diseases, Fungal / Q000209:etiology* / Q000473:pathology; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage; D009195:Peroxidase / Q000276:immunology; D011024:Pneumonia, Viral / Q000209:etiology* / Q000473:pathology; D011239:Prednisolone / Q000008:administration & dosage; D020551:Pulse Therapy, Drug; D014657:Vasculitis / Q000150:complications / Q000188:drug therapy / Q000473:pathology*
D019268:Antibodies, Antineutrophil Cytoplasmic; D011239:Prednisolone; D009195:Peroxidase; D008775:Methylprednisolone