HAIR DYE AS A COLORFUL TRIGGER FOR RELAPSE OF ANTI-GBM DISEASE

Anti-GBM (anti-glomerular basement membrane) disease is a rare, monophasic, but serious autoimmune disease involving small vessels of the kidneys and lungs. It typically presents with rapidly progressive glomerulonephritis with or without pulmonary hemorrhage. The mainstay of treatment is plasma exchange, prednisolone and cyclophosphamide. Relapse are infrequent, but may be triggered by certain environmental irritants like cigarette smoking, inhalation of solvents, hair dye or certain infections. We report a case of 43 years old male who was diagnosed anti GBM disease on kidney biopsy done for rapidly progressive renal failure. He was treated with plasmapheresis, steroids and cyclophosphamide. After two months he re-presented with diffuse alveolar hemorrhage and raised anti GBM antibodies titre which was presumed due to use of new hair dye. In view of ongoing infection and recent history of strong immunosuppressants, he was successfully treated with a non-standard regimen of plasmapheresis, intravenous immunoglobulins (IVIG) and rituximab. 

Even after 5 sessions of plasmapheresis, as anti GBM titer was still high (236 U/ml), he was administered two doses of rituximab (500mg each - 15 days apart). This resulted in rapid reduction of anti-GBM antibody titer to 88 U/ml with significant clinical improvement.

This case illustrates an unusual relapse of anti-GBM disease precipitated by hair dye exposure, successfully managed with a combination of plasmapheresis, IVIG, and rituximab. It underscores the need for vigilance regarding potential triggers of relapse. It also highlights rituximab, as a valuable therapeutic option in relapsing cases, where the standard cytotoxic therapy is contraindicated.