Goodpasture's disease complicating human immunodeficiency virus infection

Goodpasture's disease in association with human immunodeficiency virus (HIV) is rarely observed. Herein, we report a case of a 33-year-old Hispanic male who had both HIV and hepatitis C, and was subsequently diagnosed with autoantibodies to the glomerular basement membrane. On initial presentation he was anuric and hyperkalemic with an elevated creatinine. Hemodialysis was initiated, and a renal biopsy showed findings diagnostic of anti-glomerular basement membrane crescentic glomerulonephritis. Immunofluorescence microscopy showed strong (3+) linear staining of glomerular basement membranes by IgG, kappa; and lambda; light chains, and focal weaker staining of glomerular basement membranes for C3. Plasmapheresis, steroids and cyclophosphamide were all considered in treating this complex case. The patient received therapy with plasmapheresis and steroids during his initial hospitalization, but his renal function did not improve. He was discharged on hemodialysis 3 times per week. On a subsequent admission, the patient presented with symptoms and signs suggestive of pulmonary hemorrhage. Thus, plasmapheresis and cyclophosphamide were begun. His pulmonary symptoms improved with therapy, but he continued to require long-term hemodialysis. The development of Goodpasture's syndrome in a patient with HIV infection creates diagnostic and therapeutic dilemmas. The decision to treat the patient with immunosuppressive medications should lead to enhanced surveillance for infections.