Abstract: SA-PO252
A Challenging Diagnosis and a Missed Treatment Opportunity: A Case of Bartonella Endocarditis Complicated with Rapidly Progressive Glomerulonephritis
Session Information
- Trainee Case Reports - V
October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1203 Glomerular Diseases: Clinical, Outcomes, and Trials
Authors
- Mortagy, Mohamed, Western Michigan University School of Medicine, Kalamazoo, Michigan, United States
- Lamie, Lauren, WMU Homer Stryker MD School of Medicine, Kalamazoo, Michigan, United States
Introduction
Bartonella is the most common cause of culture negative endocarditis in the USA which is complicated by kidney failure in 45% of patients. Diagnosing Bartonella endocarditis is very challenging but crucial. Treating bartonella associated glomerulonephritis (GN) with immunosuppressants is fatal.
Case Description
This is a 52-year-old male with a history of bioprosthetic aortic valve replacement (AVR) who presents to the ED with 6 days of bilateral flank pain and hematuria. Physical exam was largely unremarkable including no rashes. Creatinine was 7 mg/dl. Urinalysis was remarkable for gross blood, 100 RBCs, proteinuria and RBCs casts. Imaging of abdomen and pelvis were unremarkable. Autoimmune workup was negative.
Urgent hemodialysis (HD) and corticosteroids were started. Kidney biopsy was inconclusive due to inadequate tissue. He was discharged on outpatient HD and a steroid taper. One month later, repeat kidney biopsy showed crescentic segmental necrotizing GN and focal deposits of IgM, C19 and C3 . He was readmitted for plasmapheresis and a steroid course and then discharged with maintenance HD.
Over the next 2 months, the patient had multiple episodes of fever, but blood cultures were persistently negative. After four months from initial presentation, he presented to the ED with chest pain and fever. He was diagnosed with NSTEMI. Trans-esophageal echocardiogram showed a small mildly calcified echodensity on the bioprosthetic AVR indicating endocarditis and a small echolucent area in the perivalvular region suggestive of an aortic root abscess. The patient subsequently underwent a sternotomy and aortic valve replacement. PCR performed on the vegetation was positive for Bartonella, as well as Bartonella henselae serology was positive for IgG (1/1024) and IgM (> 1/20).
Discussion
The interval development of endocarditis on echocardiogram, positive Bartonella antibodies and PCR suggest the patient developed GN associated with Bartonella endocarditis. Bartonella is a frequent cause of culture negative endocarditis. Immune deposits showing C3 dominance with IgM staining are consistent with chronic infection related GN.
This case highlights the importance of ruling out infectious etiologies of GN before starting immunosuppressants. As treating an active infection with immunosuppressive agents can be life threatening.