Abstract: SA-PO249
Necrotizing ANCA Positive Glomerulonephritis Associated in Culture Negative Endocarditis
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
- 1202 Glomerular Diseases: Immunology and Inflammation
Authors
- Mendez Castaner, Lumen Alberto, Jackson Memorial Hospital, Miami, Florida, United States
- Armstrong, Antonio A., Jackson Memorial Hospital, Miami, Florida, United States
- Abdalla, Aza, Jackson health Miami, Coral Springs, Florida, United States
- Cuebas-Rosado, Lorena, Miami VA Hospital, Miami, Florida, United States
- Thomas, David B., University of Miami, Miller School of Medicine, Miami, Florida, United States
- Mithani, Zain, University of Miami, Miami, Florida, United States
Group or Team Name
- Jackson Memorial Hospital
Introduction
Renal involvement is a common extra cardiac manifestation of infective endocarditis (IE) affecting up to 50% of all patient. Kidney manifestations in IE are variable, including direct consequence of infection such septic emboli, immune complex glomerulonephritis and more interestingly ANCA associated glomerulonephritis have been described. Making challenging the differentiation between infectious endocarditis related glomerulonephritis and small vessel vasculitis. Even more a subgroup of patient with culture negative infectious endocarditis has been associated with glomerular disease and seropositive ANCA titers caused by Bartonella species, been the most common cause of culture negative endocarditi. Diagnosis relies on clinical suspicion and serologic titers diagnostic tools.
Case Description
Case of a 73 year old with no past medical history who presented with progressive shortness of breath for 3 weeks associated with fever and chills. Complaining of bloodey sputum for the past 3 days. Physical Exam showed bilateral ronchies and crackles. Pitting edema +2. Labs serum cr 5.90mg/dL, eGFR 9mL/min/1.73m2. WBC 7.7, Hgb 6.5g/dl. UA RBC > 182, WBC 27, Upr > 100mg/dL. UPCR 4.4 , C3 73 , C4 14.8, ANCA PR3 positive. CT chest showing bilateral calcified granulomas. Echocardiogram showed 1.5 x 1.4cm calcified irregular mass noted in the tricuspid valve. Received broad spectrum antibiotics. Blood cultures negative. Renal biopsy showed crescetic focal necrotizing glomerulonephritis, with moderate fibrosis. Immunofluorescence(IF) showed mensagial IgG(1+), IgA(1+), IgM(2+), C3(2+),C1q(2+), kappa(2+) and lambda(2+). Ultrastructurally showed mesangial matrix immune complex type dense deposits. Bartonella henselae titers IgG 1:1024. Treated antimicrobial and pulse steroid followed by tapered.
Discussion
This case highlights the unique complexity in differentiating between primary small vessel vasculitis vs infectious endocarditis related glomerulonephritis, where initial serology can be misinterpreted. Ultimately with the clinical and renal biopsy findings along with bartonella titers lead to the diagnosis of culture negative endocarditis related glomerulonephritis