An "All-in-One" Kidney Biopsy in AIDS: Crescentic Immune Complex-Mediated Glomerulonephritis, CD8-Driven Interstitial Nephritis, and Superimposed Thrombotic Microangiopathy.

INTRODUCTION: Human immunodeficiency virus (HIV)-associated kidney disease encompasses a diverse spectrum of glomerular, tubulointerstitial, and vascular pathologies. While HIV-associated nephropathy and immune complex-mediated glomerular disease in the setting of HIV are well-recognized entities, their simultaneous presentation with thrombotic microangiopathy (TMA) and diffuse infiltrative lymphocytosis syndrome (DILS) has not been previously documented. We report a novel case of advanced HIV infection manifesting as crescentic lupus-like glomerulonephritis (GN), CD8-predominant tubulointerstitial nephritis, and acute TMA.

CASE PRESENTATION: A 43-year-old man presented with rapidly progressive kidney failure, nephrotic-range proteinuria, hematuria, and hypertensive emergency. Laboratory workup revealed newly diagnosed HIV infection confirmed by fourth-generation antibody assay with a CD4 count of 53 cells/µL. Kidney biopsy demonstrated a "full-house" immune complex-mediated GN with cellular and fibrous crescents involving 5 of 8 viable glomeruli, chronic active CD8+ lymphocytic interstitial nephritis, and arteriolar fibrin thrombus with endothelial injury. Electron microscopy revealed mesangial and subendothelial electron-dense deposits and tubuloreticular inclusions. No evidence of systemic lupus erythematosus, paraproteinemia, or other active infections was found. A diagnosis of crescentic immune complex-mediated GN in the setting of HIV with DILS-like interstitial nephritis and superimposed acute TMA was established. Despite antiretroviral therapy, corticosteroids, cyclophosphamide, and plasma exchange, kidney function recovery was incomplete and the patient remained dialysis-dependent.

CONCLUSION: This case represents a rare "all-in-one" manifestation involving glomerular, interstitial, and vascular injury. These findings underscore profound immune dysregulation in acquired immunodeficiency syndrome (AIDS), where immune deficiency coexists with compartmentalized immune activation. Recognition of overlapping pathology is essential for accurate diagnosis and individualized, risk-adapted management.