A case of aseptic pleuritis following repeated episodes of post-hemodialysis fever that was probably caused by ANCA-associated vasculitis

Abstract

A 60-year-old female, who had been on hemodialysis (HD) for 28 years due to drug-induced renal failure, was referred and admitted to our hospital because of a month-long post-HD fever. She had a history of pulmonary mycobacterium avium complex (MAC) infection. The fever increased after HD, but normalized by the following day. In physical, laboratory, and imaging examinations, there was no evidence of an active infection. Modifying the patient’s HD conditions, including the dialyzer membrane and anti-coagulant treatment, was ineffective against the post-HD fever. Two weeks after admission, the patient complained of right chest pain, combined with right-dominant pleural effusion and a persistent high fever. A polymerase chain reaction (PCR) test of her bronchoalveolar lavage fluid for MAC produced a negative result. Infectious pleuritis was also excluded based on bacterial cultures and a PCR test for tuberculosis. Immunological staining revealed markedly elevated levels of myeloperoxidase-specific anti-neutrophil cytoplasmic antibody (MPO-ANCA) in both serum and pleural fluid, leading to a diagnosis of suspected MPO-ANCA-associated vasculitis. The patient was treated with prednisolone after chemotherapy for pulmonary MAC disease. The fever immediately resolved after the steroid therapy, and the pleural effusion subsequently disappeared. The patient’s clinical course was strongly suggestive of aseptic pleuritis caused by MPO-ANCA-associated vasculitis. When fever occurs after HD, we need to consider both HD-related and-unrelated febrile disorders, such as vasculitis.