Abstract: SA-PO729
Gonococcal Endocarditis-Associated Glomerulonephritis: Revisiting a Forgotten Enemy
Session Information
- Glomerular Diseases: Clinical, Outcomes, Trials - III
November 05, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1303 Glomerular Diseases: Clinical‚ Outcomes‚ and Trials
Authors
- Harris, Liliia, The University of Mississippi Medical Center, Jackson, Mississippi, United States
- Sriperumbuduri, Sriram, The University of Mississippi Medical Center, Jackson, Mississippi, United States
- Syed, Bushra, The University of Mississippi Medical Center, Jackson, Mississippi, United States
Introduction
Disseminated gonococcal infection is rare in the post-antibiotic era (0.5-3.0% cases) and can be complicated by infective endocarditis (IE) and glomerulonephritis (GN). We describe a unique case of rapidly progressive GN (RPGN) secondary to gonococcal IE coinciding with complement deficiency.
Case Description
A 61-year-old male with migratory polyarthritis, recurrent UTIs and conjunctivitis presented with diarrhea, arthralgia, and skin rash. On physical exam: purpuric rash involving forearms, thighs, nasal tip and cheeks; tenderness and swelling of the right shoulder and small joints of the right foot; bilateral chronic anterior uveitis.
On initial workup (Table 1): anemia, leukocytosis, sCr of 2.98 mg/dL from baseline 0.8. Urinalysis showed proteinuria, hematuria, sterile pyuria, WBC casts. Cefepime started for empiric sepsis (Figure 1). A skin biopsy was consistent with leukocytoclastic vasculitis. Steroids were initiated due to suspected RPGN and worsened sCr. On additional workup: elevated UPCR and low C3 complement level; on renal biopsy diffuse crescentic and exudative GN with C3 deposits; favors IRGN.
ECHO revealed a multi-lobular mass 1.9x2.6 cm on tricuspid valve (TV). Steroids were held due to concern for IE. Workup for culture-negative IE was unrevealing but metagenomics sequencing of microbial cell free DNA resulted positive for Neisseria gonorrhea. Functional testing of the complement pathway revealed normal CH50 and decreased AH50 activity. He received 6-weeks of Ceftriaxone with resolution of the TV vegetation and partial renal recovery with sCr of 1.27 mg/dL.
Discussion
Complement deficient patients are highly susceptible to Neisseria infections. Dysregulation of complement pathway predisposed to C3 glomerulopathy and concomitant infection provided a second hit contributing to severe GN. Treatment with antibiotics and steroids led to partial renal recovery; further research needed on role of immunosuppression for course and outcome of IRGN.
| Admission laboratory results WBC Hemoglobin ERS CRP sCr BUN Blood culture Urine culture | Admission laboratory results 13.7 TH/cmm (4.0 –10.0) 5.7 g/dL (13.0 –17.0) 111 ml/hr (0.0 – 10.0) 13.6 mg/dL (0.0 -0.5) 2.98 mg/dL (0.67 – 1.17) 59 mg/dL (8-23) No growth after 5 days No growth |
| Complementary laboratory results UPCR Serum albumin C3 complement C4 complement Complement total (CH50) AH50, alternative complement pathway, functional Mannose binding Lectin HIV, HCV, HbsAg, HBC, HBS Cyclic Citrullinated Peptide Syphilis antibody (total) ASO screen ANA SSA and SSB antibody Rheumatoid factor Glomerular Basement Membrane Antibodies Cryoglobulin ANCA Kappa/Lambda Free light chain (FLC) ratio IFE (urine/serum) N. gonorrhea, urine C. trachomatis, urine Bartonella Hensalae, Quintana IgG Screen Bartonella Hensalae, Quintana IgM Screen Bartonella PCR (Blood) Brucella Antibody IgG Brucella Antibody IgM Tropheryma whipplei PCR (Blood) Blastomyces Antigen Histoplasma Antigen Urine Q Fever IgG Phase I Ab; II Ab Q Fever IgM Phase I Ab, II Ab Culture, AFB Blood Legionella Antigen Urine Culture, Fungus Blood Karius test: Neisseria gonorrhoeae | Complementary laboratory results 3.3 3 gm/dl 46 mg/dl (90 – 180) 18 mg/dl (10 – 40) 42 U/ml (35-70) Low, < 10 % of norm (> 46) 3390 ng/ml (>51) Non-reactive Negative Non-reactive Negative Negative < 0.2 AI (< 1.0) < 10.0 IU/ml (< 14.0) < 0.2 U (< 1.0) Negative Negative 0.845 (0.26 – 1.65) Urine and serum are negative for monoclonal FLC Not detected Not detected <1:128 (<1:128 titer) <1:20 (<1:20 titer) Not detected Negative Negative Not detected None detected Negative <1:16 (<1:16) <1:16 (<1:16) No Acid Fast bacilli isolated Negative No Growth 5309 DNA molecules/mcL (< 10) |