Bilateral vision loss as first clinical manifestation of IgA nephropathy

Background: Immunoglobulin A nephropathy (IgAN) is the most common primary glomerular disease, characterized by IgA deposition in the renal glomeruli. Its clinical manifestations range from asymptomatic hematuria to progressive chronic kidney disease (CKD), with rare cases presenting as nephrotic syndrome or rapidly progressive glomerulonephritis. The eye involvement could be present with a various spectrum of clinical presentation, unusually as first presentation and isolated. Case presentation: A 30-year-old male presented to the emergency department with rapidly progressive bilateral visual loss over two days. He had a history of mild upper respiratory symptoms treated with ibuprofen and a known history of asthma. Ophthalmologic evaluation revealed significant retinal findings, including hemorrhages, cotton wool spots, macular edema, and neurosensory detachment. His blood pressure was markedly elevated at 200/140 mmHg, prompting systemic evaluation. Laboratory tests revealed acute kidney injury with elevated creatinine and proteinuria. Renal ultrasound indicated cortical hyperechogenicity, and a renal biopsy confirmed IgAN with mesangial IgA deposition. After antihypertensive treatment and stabilization of renal function, the patient’s vision and retinal findings improved significantly over three weeks. Discussion: This case illustrates an uncommon presentation of IgAN with acute hypertensive crisis manifesting initially only as bilateral visual impairment. The retinal findings, including Roth spots and choroidal involvement, highlight the importance of ophthalmic evaluation in systemic diseases. Although hypertensive retinopathy is well documented, its association with IgAN is rarely reported in literature, especially as first manifestation. Conclusions: IgAN can present atypically with isolated ocular symptoms, underscoring the need for a comprehensive multidisciplinary approach. Clinicians should consider systemic evaluation in patients with hypertensive retinopathy and acute visual loss to facilitate early diagnosis and management of underlying renal pathology.