Pulmonary tularemia with antineutrophil-cytoplasmic-antibody-negative pauci-immune crescentic glomerulonephritis causing acute kidney injury: a case report and review of the literature

BackgroundTularemia is a zoonotic disease that is rarely diagnosed in Europe. Its clinical presentation is highly variable, requiring consideration of a broad differential diagnosis.MethodsWe present a case report of a pulmonary tularemia with antineutrophil-cytoplasmic-antibody-negative pauci-immune crescentic glomerulonephritis causing acute kidney injury, and a systematic review of the literature.Case reportWe report the case of a 73-year-old white man who presented with pneumonia, sepsis and acute kidney injury due to a pauci-immune crescentic glomerulonephritis with negativity for antineutrophil cytoplasmic antibodies. Initial management with dialysis, empirical antibiotics, and immunosuppression was adjusted after identification of Francisella tularensis, and targeted antibiotic therapy was administered successfully. At 4 years of follow-up, no recurrence was observed.Literature reviewOur review of the literature identified only a few case reports of tularemia complicated by acute kidney injury. None documented biopsy-proven pauci-immune crescentic glomerulonephritis.ConclusionPulmonary tularemia complicated by acute kidney injury is an uncommon clinical constellation. Biopsy-proven pauci-immune crescentic glomerulonephritis with antineutrophil-cytoplasmic-antibody-negativity in this setting appears to be very rare. Careful differential diagnosis, early recognition of tularemia, and timely initiation of effective antibiotic therapy are critical to achieving favorable outcomes.