Abstract: PUB385
Unveiling the Hidden Culprit: Glomerulonephritis and Hand Lesions Leading to Infective Endocarditis
Session Information
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Alshehri, Mohammed, King Khalid University College of Medicine, Abha, Saudi Arabia
- Abdi, Ali Awil, Fakeeh Care, Jeddah, Makkah, Saudi Arabia
- Al mosa, Hussain M., Aseer Central Hospital, Abha, Saudi Arabia
Introduction
We present a case of Rapidly Progressive Glomerulonephritis associated with Staphylococcus aureus mitral valve infective endocarditis (IE). The patient developed lesions on the palms and soles, which led to the discovery of a large vegetation.
Case Description
A 31-year-old woman with hypertension was advised to go to the ER for high serum creatinine (2.3 mg/dl).Blood pressure was 199/153 mmHg, heart rate 94 bpm, oxygen saturation 99%, and temperature 36.8°C. Urine dipstick showed +3 blood and +2 protein. CBC was unremarkable, but creatinine rose to 4 mg/dl with sub-nephrotic range proteinuria and 10-20 RBCs in urine. Steroid was started, and kidney biopsy was arranged. Immunological workup revealed low C3, with negative ANA, ANCA, hepatitis, and HIV. The biopsy showed significant atrophy, leading to tapering of steroid and dialysis/transplant discussion.
Two weeks later, she presented with sepsis, anuria, lethargy, and serum creatinine of 6.2 mg/dl. Exam of her palms and soles revealed Osler’s nodes,
Janeway lesions, and splinter hemorrhages. She had thrombocytopenia without hemolysis. Blood cultures were positive for MSSA. Echocardiograms showed a sub-mitral vegetation (2.6x1.2 cm). A CT angiogram ruled out renal artery stenosis but detected splenic infarction. The patient remained on dialysis and underwent surgical removal of the vegetation and mitral valve replacement.
Discussion
Subacute IE can present with an indolent course, causing delayed diagnosis. We present a case initially showing nephritis and low C3. Classical signs of microemboli and positive blood cultures led to the diagnosis. Consistently low C3 level suggests clinicians should consider an echocardiogram in cases of unexplained glomerulonephritis.
Summary of kidney biopsy findings
| LM The specimen contains 15 glomeruli; 2 (~13%) are globally sclerosed. +Glomerular ischemia, marked corrugation, focal fibrous obliteration, and thickened Bowman | IF Staining shows granular nonspecific mesangial C3 (1+), focal segmental IgM (1+), and trace Kappa and Lambda light chains in a sclerotic tuft. | EM Mesangium shows segmental expansion with increased matrix and segmental capillary obliteration. The GBM is corrugated and thickened, without attenuation, double contouring, or lamellation. The foot processes are effaced over a long segment, and focal microvillous transformation of podocyte cytoplasm is noted. No definite immune/complement dense deposits are identified. |
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