POS-143 SYPHILIS INDUCED MEMBRANOUS NEPHROPATHY. A CASE REPORT

Abstract

The rate of reported cases of syphilis is rising. More than 85% of primary and secondary syphilis occurs in men. This is attributed to increased cases of men who have sex with men. It accounts for more than 50% of all cases of primary and secondary syphilis. Renal manifestations of syphilis may present with variable degrees of proteinuria, acute nephritis with hypertension (HTN) or acute kidney injury (AKI). Pathologically, membranous or endocapillary GN may be seen. We present a case of secondary syphilis in a young man with severe nephrotic syndrome, AKI and HTN A 28 years old male patient presents to the ER with severe facial edema for 2 days and skin rash for one week. He presents mouth and genital ulcers one month ago. He has no urinary symptoms, headache, fever or arthralgia. He had multiple unprotected sexual relations with the same sex for few months. His past and family history is irrelevant, and he doesn’t take any medication. Physical examination reveals generalized edema, maculopapular rash all over the body and increased blood pressure. Chest, heart, abdominal and neurological examination in normal. nPCR testing of CSF is negative. Lab work shows severe nephrotic syndrome with 24 h proteinuria of 32.89 g and serum Albumin of 9 g/L. Urine sediment reveals hyaline, granular, waxy casts and microscopic hematuria. Serum creatinine is increased with very low natriuresis denoting prerenal factor due to severe hypovolemia secondary to nephrotic syndrome. Liver enzymes are elevated. Blood picture is normal. Immunological profile including ANCA, Anti GBM, ANA, Anti ds DNA, ENA screen, RF, C3, C4, PPE is normal. VRDL and Syphilis RPR returns positive. Serology of other sexually transmitted and infectious diseases as HIV, HBV, HCV, CMV, Toxoplasma, gonorrhea, chlamydia is negative. Renal biopsy makes the diagnosis of Membranous Nephropathy (MN) stage 1. The absence of PLA2R antibodies and IgG4 with the predominance of IgG3 favors secondary form of MN. The patient received Benzathine penicillin, Albumin/Furosemide, anti-hypertensive treatment and thromboprophylaxis. Prognosis is excellent with dramatic response to penicillin, disappearance of proteinuria and normalization of renal function and liver enzymes after 4 weeks. The presence of nephrotic syndrome with maculopapular rash occurring in a male patient with history of unprotected sexual relations with the same sex may be related to renal complication of syphilis. The most common pathology is MN. Treatment of the cause is associated with complete cure and excellent prognosis.