Anti-GBM Glomerulonephritis (GN) and Phospholipase A2 Receptor (PLA2R)+ Membranous Nephropathy (MN) Due to Possible Hydrocarbon Exposure (HC) with Renal Recovery

Introduction: Concurrent anti GBM GN and MN remains rare with guarded renal prognosis. Only 1 case is described in the setting of HC exposure and that patient required HD at 1 year. Hairdressers are exposed to volatile organic compounds which includes volatile HC. Ours is the 1st concurrent anti GBM GN and PLA2R MN case with possible HC exposure and renal recovery. Case Description: A 61-year-old previously healthy female hairdresser presented to the ED with 2 days of hemoptysis and poor oral intake after recent URI. She was hypoxic with mixed nephritic/nephrotic syndrome (Table 1). She required intubation on hospital day (D)2. D3 Bronchoscopy noted diffuse alveolar hemorrhage and anti GBM Ab returned positive, so steroids and daily PLEX were begun. HD was initiated D5 for uremia. D6 renal biopsy (Figure 1) LM showed diffuse crescentic and segmentally necrotizing GN (up to 76% glomeruli), thick glomeruli capillary walls with spikes, pinholes and 4+ IgG by IF. IF glomerular deposits were anti PLA2R+. EM showed subepithelial electron dense deposits. IgG subclasses were 3+ granular IgG4 and 2-3+ linear IgG1. The final diagnosis was concurrent MN and anti GBM GN. She received PLEX until anti GBM Ab was undetectable, PO cyclophosphamide (3 months) and steroids (6 months). Renal function recovered, and dialysis was stopped after 5 sessions. Discussion: She likely had HC exposure as a hairdresser in a poorly ventilated salon. We suspect underlying MN due to HC exposure revealing antigenic sites on type IV collagen of the GBM leading to anti GBM GN. Concurrent anti GBM GN and anti PLA2R MN in the setting of HC was once reported, but our patient had renal recovery. Prognosis could be more favorable with early diagnosis and treatment.