Acute Ischemic Stroke as a Presenting Feature of Primary Membranous Nephropathy: A Rare and Under-Recognized Association

Background: Nephrotic syndrome is classically associated with venous thromboembolism, but arterial events such as ischemic stroke remain rare and under-recognized. Primary membranous nephropathy (PMN) is a common cause of nephrotic syndrome in adults; however, cerebrovascular events seldom constitute the initial presentation. A 42-year-old Case Presentation: man, chronic smoker and alcohol user with no prior comorbidities, presented with acute slurred speech and right-sided hemiparesis. Neuroimaging revealed a left middle cerebral artery infarct with complete occlusion of the left internal carotid and middle cerebral arteries. Laboratory evaluation showed severe hypoalbuminemia (1.8 g/dL), nephrotic-range proteinuria (6.3 g/day), and strongly positive anti-PLA2R antibody (276.6 RU/mL), confirming PMN. Hypercoagulability work-up demonstrated reduced antithrombin III and markedly elevated fibrinogen. Secondary causes of nephrotic syndrome were excluded. The patient was initiated on high-dose corticosteroids and planned for the modified Ponticelli regimen alongside standard stroke management. This case highlights ischemic strok Conclusion: e as a rare but serious initial manifestation of PMN.Nephrotic syndrome should be considered in young patients presenting with stroke, especially in the absence of conventional vascular risk factors. Early recognition and treatment of the underlying renal disease are critical for improving outcomes.