Anti-GBM antibody disease sans crescents with thrombotic microangiopathy

We report a case of a 38-year-old male with acute renal failure, elevated anti-glomerular basement membrane (anti-GBM) antibody titres, bilateral nodular lung opacities and hypertension. In the renal biopsy examination, whereas direct immunofluorescence revealed significant peripheral linear deposits of IgG typical of anti-GBM antibody disease (Goodpasture's disease), eosin-haemotoxylin staining showed glomerular and vascular changes typical of thrombotic microangiopathy (TMA) and without crescents. We postulate that the TMA was responsible for the acute renal failure and that antibodies, though demonstrable, were not adequate at the site of the glomerular basement membrane to elicit a crescentic response, because of occlusion of the vascular lumina by the thrombotic process. The patient remained dialysis dependent at a 3-month follow-up.