antineutrophil cytoplasmic antibodies ( anca)-associated glomerulonephritis ( gn ) is characterized by necrotizing and crescentic gn with paucity of immunoglobulin ( ig ) and complement deposition , which is also known as pauci - immune crescentic gn .
membranous nephropathy ( mn ) is characterized by the formation of subepithelial immune deposit with resultant changes in glomerular basement membrane ( gbm ) , most notably spike formation .
a 48-year - old man presented with marked proteinuria , hypoalbuminemia , and renal dysfunction with positive results for myeloperoxidase ( mpo ) and anca .
renal biopsy revealed crescents and thick gbm with subepithelial spikes along with igg deposition on immunofluorescent staining .
after one - month follow - up , antibody level and renal function did not improve .
coexistence of mn with mpo - anca crescentic gn is very rare and should be managed aggressively .
membranous nephropathy ( mn ) is characterized by the formation of subepithelial immune deposit with resultant changes in glomerular basement membrane ( gbm ) , most notably spike formation .
approximately 75% of mn represent as primary disease and the rest results from secondary causes , most commonly systemic lupus nephritis ( sle ) , infections such as hepatitis b or c viruses , malignancy , or drugs .
antineutrophil cytoplasmic antibodies ( anca)-associated glomerulonephritis ( gn ) is characterized by necrotizing and crescentic gn with paucity of immunoglobulin ( ig ) and complement deposition , which is also known as pauci - immune crescentic gn ( 1 - 3 ) .
we report a rare case of mn with myeloperoxidase ( mpo)-anca - associated crescentic gn in a 48 year - old - man who was admitted to our institute .
a 48-year - old man presented with intermittent puffiness of face and edema of the feet for two months .
he did not have fever , hematuria , or breathlessness . on examination , he had bilateral pitting pedal edema ( + + ) , pulse rate of 98 per minute , and blood pressure of 140/96 mm hg .
cardiovascular and respiratory examinations were unremarkable . on investigation the following laboratory results were reported : hemoglobin , 6.1 gm / dl ; white blood cell ( wbc ) count , 5.6  10/l ; platelet count , 2.11  10/l ; blood urea nitrogen , 35 mmol / l ; serum creatinine , 807 mol / l ; random blood sugar , 5.33 mmol / l ; total serum protein , 500 g / l ; serum albumin , 31
g / l ; serum sodium , 132  mmol / l ; serum potassium , 4.54   mmol / l ; and serum cholesterol , 5.28 mmol / l .
urine analysis showed 3 + albumin with 35 to 40/hpf of red blood cells and 8 to10/hpf of wbc .
results of viral screening for human immunodeficiency virus , hepatitis b and hepatitis c viruses were negative .
serum mpo - anca level was 220 u / ml ( normal range , 1 - 5 ) .
serum anti - nuclear antibody ( ana ) , the levels of serum complements c3 and c4 were in normal limits .
chest radiograph revealed normal findings and renal ultrasonography showed right kidney dimension of 8.6  3.4 cm and left kidney dimension of 9.0  4.5 cm , with increased echogenicity and maintained corticomedullary differentiation .
renal biopsy was performed and after paraffin embedding , 3-m - thick sections were prepared and stained by hematoxylin and eosin ( h and e ) , periodic acid schiff , jone s silver methenamine , and gomori s trichrome stains .
histopathologic examination ( figures 1 and 2 ) showed a single core of renal tissue containing 14 glomeruli with surrounding tubules and vessels .
immunofluorescence ( if ) studies ( figure 3 ) showed fine granular fluorescence ( + 3/4 ) across 80% to 90% of glomerular capillary walls on staining with anti - human igg .
no fluorescence was revealed on staining with anti - human iga , c3 , c1q , fibrinogen , and igm antisera .
he was diagnosed as a case of mpo - anca - associated crescentic gn with mn .
he was treated with intravenous methylprednisolone ( 500 mg / d ) for three days , followed by intravenous cyclophosphamide ( 500 mg ) and oral prednisolone ( 0.5 mg / kg / d ) with antihypertensive drugs .
after two - month follow - up , his serum creatinine was 389 mol / l , urine albumin was 3 + with 5 to 7/hpf of rbcs .
his renal biopsy revealed crescents and thick gbm with subepithelial spikes along with igg deposition on if staining .
coexistence of anca - gn with mn is very rare ( 1 , 4 - 7 ) .
surindran et al . detected coexistence of anti - phospholipase a2 receptor antibody ( pla2r)-positive mn and anca - gn ( 9 ) .
ram et al . reported mn superimposed on churg - strauss syndrome ( 10 ) . the combination of anti gbm - gn and mn are also reported ( 11 , 12 ) .
nasr et al . and nayak et al . reported that mn preceded the development of anti gbm in 50% of cases ( 1 , 13 ) .
morizane et al . have reported a case of mpo - anca - associated gn , which was superimposed on type-3 mpgn .
mn can be classified into primary and secondary forms according to igg subclass . in primary mn , igg4 is positive and in secondary mn , igg1 and igg4 .
speculated that mpo - anca - associated gn might cause secondary mn as both igg1 and igg4 were present in their case ( 4 ) .
the membranous lupus nephritis ( ln ) with focal or diffuse ln may have crescents with mn .
such mixed patterns of ln have endocapillary proliferation and concomitant subendothelial immune deposits with full - house staining by if .
nasr et al . reviewed kidney biopsies from january 2000 to february 2008 and concluded that coexistence of mn and anca - associated gn would be coincidental ( 1 ) . the primary mn is associated with hla - dq1 and pla2r , suggesting genetic predisposition ( 9 , 15 ) .
anca - associated gn is also associated with environmental triggers such as drugs and infections ( 9 ) .
when patient presents as rapidly progressive glomerulonephritis with marked proteinuria , further investigations to rule out possibility of mn with anca associated crescentic gn should be performed and the patient should be managed aggressively .
 introduction : antineutrophil cytoplasmic antibodies ( anca)-associated glomerulonephritis ( gn ) is characterized by necrotizing and crescentic gn with paucity of immunoglobulin ( ig ) and complement deposition , which is also known as pauci - immune crescentic gn . 
 membranous nephropathy ( mn ) is characterized by the formation of subepithelial immune deposit with resultant changes in glomerular basement membrane ( gbm ) , most notably spike formation.case presentation : a 48-year - old man presented with marked proteinuria , hypoalbuminemia , and renal dysfunction with positive results for myeloperoxidase ( mpo ) and anca . 
 renal biopsy revealed crescents and thick gbm with subepithelial spikes along with igg deposition on immunofluorescent staining . 
 the condition was diagnosed as mn with mpo - anca - associated crescentic gn . 
 he was treated with intravenous methylprednisolone and cyclophosphamide . 
 after one - month follow - up , antibody level and renal function did not improve.conclusions:coexistence of mn with mpo - anca crescentic gn is very rare and should be managed aggressively . 
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Case Presentation:
Conclusions:
1. Introduction
2. Case Presentation
3. Discussion