A Pathogen's Whisper: Reactivation of Quiescent Membranous Nephropathy by Disseminated Tuberculosis

Primary membranous nephropathy (MN) is an autoimmune glomerular disease commonly associated with anti-PLA2R antibodies, with relapses typically attributed to spontaneous immune reactivation. We report the first documented case of a relapse of primary, PLA2R-positive MN that was temporally and immunologically linked to disseminated tuberculosis (TB) infection. A 42-year-old man, previously in complete remission, developed severe nephrotic syndrome and acute kidney injury unresponsive to standard immunosuppressive regimens. Concomitant diagnosis of miliary TB was confirmed by culture and imaging. Remarkably, the MN relapse resolved completely with anti-TB therapy alone, without further immunosuppression, and remission has been sustained for over two years. This case highlights infection, specifically TB, as a modifiable and overlooked trigger of MN relapse, potentially via molecular mimicry or system immune activation. In TB-endemic regions, identifying infectious triggers early in relapsing MN may spare patients from unnecessary immunosuppression and facilitate long-term remission through targeted antimicrobial therapy.