Immunotactoid Glomerulopathy in a Patient With HIV and Anti-hepatitis C Virus (HCV) Positivity: A Unique Clinical...

Immunotactoid glomerulopathy (ITG) is a rare glomerular disease characterized by organized immunoglobulin deposits forming microtubular structures on electron microscopy. While ITG has been individually associated with HIV and hepatitis C virus (HCV) infections, there are few case reports with concurrent HIV infection and anti-HCV antibody positivity. We report a 57-year-old Hispanic female with HIV infection since 2007 and positive anti-HCV antibodies who presented with nephrotic-range proteinuria (urine protein-to-creatinine ratio: 7,834 mg/gm), hematuria, and hypertension. Renal biopsy revealed enlarged glomeruli with diffuse mesangial expansion, segmental endocapillary proliferation, and characteristic organized microtubular deposits on electron microscopy. Immunofluorescence demonstrated granular staining for IgG (both IgG1 and IgG2 subclasses), kappa and lambda light chains, and C3, confirming polyclonal ITG. Extensive hematologic workup was negative for lymphoproliferative disorders. Given the patient's immunocompromised status, immunosuppressive therapy was avoided. Treatment focused on optimizing antiretroviral therapy, transitioning from oral to long-acting injectable regimens (including lenacapavir), which improved viral suppression and CD4 counts. Proteinuria management included angiotensin-converting enzyme inhibitors and sodium-glucose cotransporter-2 (SGLT2) inhibitors, resulting in significant proteinuria reduction while maintaining preserved renal function (serum creatinine ≤1.0 mg/dL). This is a unique case of ITG in a patient with concurrent HIV infection and anti-HCV seropositivity. Our case demonstrates that polyclonal ITG in immunocompromised patients can be effectively managed without immunosuppression through optimized antiretroviral therapy and nephroprotective agents, including SGLT2 inhibitors. This approach offers a novel therapeutic strategy that avoids the risks of immunosuppression in vulnerable populations while achieving favorable clinical outcomes.