PMC9537632_01
Kidney biopsy: an overview of a PAS-stained kidney biopsy, showing large cellular crescent present in all glomeruli (as highlighted by the circles), in line with a severe presentation of anti-glomerular basement membrane (anti-GBM) disease. Concomitant tubulo-interstitial nephritis (arrows) and signs of severe acute tubular injury with red blood cells within the tubular lumina (asteriks). Bar = 500 mum (A). Immunohistochemical staining with the antibody against IgG, showing a linear staining pattern of the glomerular basement membrane (B).
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F1
Thus, a kidney biopsy was performed, and the diagnosis of double-positive disease was made (Figures 1A,B).
Electrocardiogram showing ST-segment depression in II, III, aVF (A), and V4-V6 (B). Electrocardiogram (with a paper speed of 50 mm/s) 1 month before MINOCA (C).
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F2
Electrocardiogram (ECG) showed ST depressions in leads II, III, aVF, and V4 to V6 (Figures 2A,B), which changes were absent in a previous ECG 1 month before (Figure 2C).
Coronary angiography without significant obstructive coronary artery disease. (A) cranial, 40  (B) RAO, 20 ; caudal, 30  (C) LAO, 90  (D) RAO, 90  (E) LAO, 30 .
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F3
High-sensitive troponin T (hs-Tn) was elevated (the baseline level: 1,514 pg/ml; normal range: <14 pg/ml); thus, the diagnosis of non-ST elevation myocardial ischemia was made (Figure 3). Urgent coronary angiography (CA) excluded obstructive coronary artery disease (CAD) in major epicardial vessels and did not show signs of ruptured plaque or dissection, suggesting the diagnosis of MINOCA (Figures 3A-E).
Laboratory charts of the time-dependent development of high-sensitive (hs) troponin T (A) and myeloperoxidase anti-neutrophil cytoplasm (MPO-ANCA) and anti-glomerular basement membrane (anti-GBM) antibodies (B). Zero on both scales indicates the time point of chest pain.
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F4
Notably, ANCA positivity was seen throughout the disease course, while hs-Tn decreased significantly a few weeks after the cardiac event (Figure 4).