Case Presentation: The patient is a 76-year-old male with a PMHx of DM2, HTN and HLD who presented with a complaint of bloody urine in addition to fevers and chills for a day. He denied any past history of bloody urine. The patient also pointed out that he has had a new painless right lower eyelid lesion for a month and a left cheek lesion for 4-5 years. Physical exam revealed a temperature of 38.1C, few basilar crackles and trace lower extremity edema. Pertinent labs revealed proteinuria and numerous RBCs in UA. His creatinine was elevated to 1.52 and CXR showed trace pleural effusions and pulmonary edema. The clinical diagnosis for this patient was vasculitis and /or pneumonia, for which he was treated with a short course of IV antibiotics. CT scan of abdomen ruled out renal calculus and other intra-abdominal pathology. His pertinent autoimmune work up was positive for PR3 but was otherwise negative. He was started prednisone for suspected vasculitis and renal biopsy was performed, which was consistent with IgA nephropathy. He was continued on prednisone, and his hematuria and fever resolved. Subsequently, he underwent biopsies of the right eyelid and left cheek lesions, which were consistent with squamous cell carcinoma.
Discussion: IgA nephropathy is often referred to as synpharyngitic hematuria because it usually presents with gross hematuria that occurs in conjunction with a URI, which was the case for this patient. It most often occurs in the second or third decade of life. IgA nephropathy has previously been found to be associated with renal, lung and gastrointestinal carcinomas [1]. Here we present a rare case of late onset IgA nephropathy in a 76-year-old male in association with squamous cell carcinoma (SCC) of the skin, which has not been previously reported.
The unusual late onset of IgA nephropathy in this elderly patient correlates with the development of a new right lower eyelid lesion that was present for only a month, which was found to be SCC. It was previously shown that SCC is associated with elevated IgA levels, which can lead to subsequent immune complex deposition in the kidney and contribute to the pathogenesis of IgA nephropathy in a genetically predisposed patient [2]. Therefore, it can be hypothesized that the development of the patient’s new SCC lesion represented worsening of patient’s pre-existing SCC burden with concomitant elevations of IgA levels, which helped to contribute to the development of the patient’s IgA nephropathy as part of a paraneoplastic syndrome.
Conclusions: It is important for hospitalists to be cognizant that IgA nephropathy can have a late onset and may occur as part of a paraneoplastic syndrome, particularly in an elderly patient. Therefore, if IgA nephropathy is diagnosed in an elderly patient, it is relevant for a hospitalist to look for findings suggestive of malignancy. In this case, IgA nephropathy was associated with SCC of the skin, which has not been previously reported.
References:
1. Bacchetta J, et al. Paraneoplastic glomerular diseases and malignancies. Critical Reviews in Oncology/Hematology. 2009;70(1):39-58.
2. Mishra R, et al. Evaluation of Serum IgA level in nontreated and treated oral squamous cell carcinoma patients. Journal of Indian Academy of Oral Medicine and Radiology. 2018;30(1):10.