Atypical Presentation of Crescentic IgAN in a Young Woman with Pericardial Effusion

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Introduction: While IgA nephropathy (IgAN) is typically an indolent glomerulonephritis, crescentic IgAN is a rare and aggressive variant that can mimic systemic vasculitis and rapidly progress to end-stage renal disease (ESRD). Even more uncommon is the coexistence of moderate-to-large pericardial effusion with early tamponade physiology at initial presentation. This case underscores the importance of high clinical suspicion and early biopsy in atypical AKI presentations. Case Description: A 22-year-old woman presented with chest pain, dyspnea, and fatigue. Vitals: BP 209/123 mmHg, HR 110 bpm. Echocardiogram revealed moderate pericardial effusion with early tamponade signs. Labs showed severe AKI (Cr 11.3 mg/dL, BUN 66 mg/dL), Hb 8.8 g/dL, and troponin 88 ng/L. Urinalysis revealed 84 RBCs/HPF, >1000 mg/dL protein, and UPCR 9.4 g/g. She reported gross hematuria during three prior COVID-19 infections and chronic NSAID use for menstrual pain. Autoimmune, infectious, and paraprotein workups were negative. A renal biopsy revealed crescentic IgAN with 52% global glomerulosclerosis, acute tubular injury, and marked interstitial fibrosis. She was started on urgent hemodialysis for uremia and volume overload. A follow-up echocardiogram showed resolution of the pericardial effusion, but she remains dialysis-dependent. Discussion: This rare and fulminant case of crescentic IgAN with pericardial involvement highlights the importance of early recognition in patients with COVID-19-associated hematuria and chronic NSAID use. The combination of these factors with rapid clinical decline likely triggered an aggressive disease course. Vigilant monitoring of renal function and urinalysis following COVID-19 infection, along with timely biopsy, is essential for guiding management and improving prognosis. This case underscores the need to consider crescentic IgAN in AKI with systemic features, as early detection and treatment may prevent irreversible kidney failure.

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