Elderly Woman with History of Sjogren Syndrome and Rheumatoid Arthritis Develops Cryoglobulinemia-Related Crescentic Membranoproliferative Glomerulonephritis (MPGN)

Introduction: We have a 82 year old lady with h/o rheumatoid arthritis and Sjogrens syndrome seen in clinic with edema, microscopic hematuria, proteinuria and biopsy revealed MPGN with focal crescents and positive cryoglobulins,SS-A, RF and PR-3 positive. Case Description: A 82 year old lady with h/o rheumatoid arthritis and Sjogrens syndrome (chronic xerostomia, chronic dry mouth, well controlled on conservative treatment) seen in clinic for edema, resistant Hypertension, microscopic hematuria, severe proteinuria. urinalysis showed urine protien 30, moderate blood, RBC 10, WBC 18. Work up revealed Cr jumped from 1.0 to 1.8 mg/dl, UP/UC 4.30 g/g, cryoglobulin 8%, ANA titer 1:320, C3 59 and C4 <2, SS-A > 8.0, RF >650, PR-3 Abs were positive (3.0). Kidney biopsy showed MPGN with Focal Crescents, Immune Complex Type. Out of 39 glomeruli, 12 of which are globally sclerotic and clustered within the subcapsular cortical areas. Other glomeruli show diffuse membranoproliferative features with a lobulated contour of glomerular tufts. Seven glomeruli show segmental cellular crescents. IF revealed global granular mesangial and capillary loop staining for IgG (3+), IgM (2+), C3 (1+), kappa (3+) and lambda (2+). Started oral prednisone and rituximab infusions and referred to Rheumatology. Discussion: Usually Sjogren syndrome and RA doesnt involve Glomerulus and this is rare presentation involving in an Octogenerian groups which has good prognosis with treatment.Cellular CrescentGBM wide double contours