Urinalysis revealed 12 red blood cells (RBCs) per high-power field, 4 white blood cells (WBCs) per high-power field, and 0.631 gm/day protein with albumin (2+). A serum creatinine level of 0.8 mg/dl was reported on routine laboratory evaluation few months ago. Echocardiography revealed normal left ventricular ejection fraction (60%), mild concentric left ventricular hypertrophy and grade I left ventricular diastolic dysfunction.

Following this she was started on antibiotics, NSAIDS, and methylprednisolone. As the serum creatinine level did not improve, she was referred for nephrology consultation. She was planned for kidney biopsy and was started on cyclophosphamide. Blood transfusion was done. Renal biopsy revealed necrotizing and crescentic glomerulonephritis with insignificant glomerular immune complex deposit suggesting ANCA associated glomerulonephritis in the view of history of ANCA positivity (Figure 1). She was discharged after 10 days of hospitalization.