Successful recovery of infective endocarditis-induced rapidly progressive glomerulonephritis by steroid therapy combined with antibiotics: a case report

Bartonella henselae Infective Endocarditis: A Rare Cause of Pauci-Immune Necrotizing Glomerulonephritis-A Case Report

Rationale

Bartonella sp. are the most common causes of culture-negative infective endocarditis (IE) cases in the United States. Although, infection-related glomerulonephritis can frequently mimic primary vasculitis due to pauci-immune pattern, majority of previously reported cases of Bartonella henselae-associated glomerulonephritis have immune-complex deposits on immunofluorescence. We present a rare case of B henselae IE-related pauci-immune necrotizing glomerulonephritis. Timely recognition of this atypical presentation led to appropriately directed medical therapy.

Presenting concerns of the patient

A 33-year-old Caucasian male with a history of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART), alcohol abuse, previous subarachnoid hemorrhage (SAH), and recent wisdom tooth extraction (on amoxicillin) was transferred from an outside hospital for further evaluation of severe headache. He was diagnosed with an SAH and right anterior cerebral artery mycotic aneurysm. The serum creatinine at the outside hospital was 292 umol/L (3.3 mg/dL) with a previously normal baseline around 2 years ago. The serum creatinine at our institution was 256 umol/L (3.0 mg/dL). The urinalysis demonstrated +100 protein, +3 blood and 29 red blood cells/high power field. The urine protein creatinine ratio (UPC) was 1.7 g/g. Serologic evaluation was positive for a low C4 10.2 mg/dL, elevated rheumatoid factor 40 IU/mL and an elevated proteinase 3 (PR-3) antineutrophilic cytoplasmic antibodies (ANCA Ab) 4.0 U/mL. A transesophageal echocardiogram (TEE) showed echo densities on both mitral and aortic valve. Blood cultures were negative. Further serologic evaluation was positive for B henselae IgG titer of 1:2560 (normal <1:320) with a negative IgM titer.

Diagnoses

A percutaneous kidney biopsy revealed pauci-immune necrotizing glomerulonephritis, with 14/16 glomeruli globally sclerotic, and 2 glomeruli with active segmental necrotizing lesions. There was no evidence of immune-complex deposition on immunofluorescence or electron microscopy. Clinical findings were consistent with B henselae IE associated mycotic aneurysm and necrotizing glomerulonephritis.

Intervention

Empiric treatment for an active glomerulonephritis with immunosuppressive agents was deferred on admission, given concern for an underlying infectious process and mycotic aneurysms in an HIV-positive patient. He received antibiotic treatment with doxycycline and ceftriaxone with gentamicin for synergy. Despite this, the mitral and aortic valve regurgitation worsened, and he developed congestive heart failure requiring aortic valve replacement and mitral valve repair. The explanted aortic valve was positive for B henselae by polymerase chain reaction (PCR) confirming the diagnosis of B henselae IE.

Outcomes

Immunosuppression was deferred due to timely identification of an atypical presentation of B henselae-associated ANCA antibodies-positive, pauci-immune necrotizing glomerulonephritis. A course of antibiotic treatment resulted in improved renal functions along with undetectable B henselae and PR3 Ab titers. The serum creatinine decreased to 176 umol/L (2 mg/dL) and remained stable 12 months after discharge.

Teaching points

B henselae IE should be suspected in patients with pauci-immune necrotizing glomerulonephritis and culture-negative IE. This is imperative for optimal decision making in the management of such patients. Having high clinical suspicion can avoid unnecessary and potentially deleterious use of immunosuppressive agents.

Systemic Bartonellosis Manifesting With Endocarditis and Membranoproliferative Glomerulonephritis

Cat scratch disease caused by Bartonella species is mostly benign and self-limiting condition. Systemic infection is uncommon in immunocompetent host. We describe the case of a 66-year-old male who presented with sudden painless left eye blindness and brown-colored urine. Laboratory findings revealed progressively rising serum creatinine in association with nephrotic-range proteinuria at 7 g/day and glomerular hematuria on urinalysis. An echocardiogram demonstrated mitral and tricuspid valve vegetations despite multiple negative blood cultures. The left eye blindness was attributed to retinal artery occlusion from septic valvular embolus. Kidney biopsy showed membranoproliferative glomerulonephritis pattern of injury with "full house" pattern on immunofluorescent staining with subendothelial deposits on electron microscopy. Markedly elevated IgG (immunoglobulin G) titers for B henselae and B quintana were discovered. The patient had several cats at home. Kidney failure rapidly progressed to require hemodialysis. Once the diagnosis of systemic bartonellosis was confirmed, doxycycline (for 4 months) with rifampicin (for 3 months) were initiated. Repeat echocardiogram in 4 months demonstrated a resolution of valvular vegetations; however, the left eye blindness was permanent. In the present case the correct diagnosis of systemic bartonellosis allowed institution of appropriate antibiotic therapy and to also achieve a partial recovery of renal function and to discontinue hemodialysis.

Antineutrophil cytoplasmic antibody-positive infective endocarditis complicated by acute kidney injury: a case report and literature review

Patients with infective endocarditis (IE) may present with multisystem disturbances resembling autoimmune diseases, such as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). The kidneys are susceptible to damage in IE and AAV, which is a source of diagnostic ambiguity. Therefore, distinguishing infection from an inflammatory process is pivotal for guiding appropriate therapy. We report a 22-year-old man with IE characterized by ANCA positivity and complicated by acute kidney injury. A renal biopsy showed crescentic nephritis with tubulointerstitial lesions. However, transthoracic echocardiography and blood culture provided evidence of IE, and AAV was ruled out. Surgical intervention and antibiotic treatments were successful. We summarized previously reported cases of ANCA-positive IE that had renal biopsy data. We found that ANCA-positive IE can involve multiple organs. The representative renal pathology was crescentic nephritis, focal segmental glomerulonephritis, mesangial cell proliferation, tubular injury, and interstitial oedema. Immunofluorescence showed predominate C3 deposits. Electron microscopy showed electron-dense deposits in the subendothelial or mesangial areas. Eight patients received immunosuppressive therapy with excellent results. Repeated testing for bacterial pathogens and multiple renal biopsies may be useful for diagnosing ANCA-positive IE. With ANCA-positive IE, immunosuppressive therapy along with antibiotic treatments may be beneficial for recovery of renal function.

Infective endocarditis mimicking ANCA-associated vasculitis: does it require immunosuppressive therapy?: A case report and literature review

RATIONALE

In the course of endocarditis, the development of antineutrophil cytoplasmic antibody (ANCA)-mediated disease introduces the dilemma of determining the best treatment approach for immune conditions, whether immunosuppressant therapy should be added to antibiotic treatment has remained controversial.

PATIENT CONCERNS

A 33-year-old man presented with progressive fever lasting for 7 months, and swelling, pain, and purpura in the arms and legs. The patient showed multiple autoantibodies including cytoplasmic ANCA, antiproteinase 3, rheumatoid factor, and anti-beta 2 glycoprotein I. Blood culture was positive for viridans streptococcus, and renal biopsy revealed glomerulonephritis and interstitial nephritis.

DIAGNOSIS

Endocarditis caused by viridans streptococci, ANCA-associated vasculitis, and congenital ventricular septal defect.

INTERVENTIONS

In addition to effective antibiotics, he also received twice intravenous corticosteroids and intravenous immunoglobulin therapy, and a low dose of cyclophosphamide. At last, the patient received congenital ventricular septal defect repair and debridement.

OUTCOMES

The abnormal clinical manifestations, including renal failure and loss of strength, recovered rapidly with corticosteroid therapy in addition to antibiotic treatment. After 6 months without any medications, he remained asymptomatic and was able to live normally.

LESSONS

In this case with endocarditis and ANCA-associated vasculitis, we highlighted the importance of biopsy and immunosuppressive therapy. Histopathologic examination is required for diagnosis and treatment in such case. Identifying patients who have endocarditis and ANCA positivity with vasculitis pathologic features will require corticosteroid/immunosuppressives in addition to the antibiotics therapy.

Glomerulonephritis triggered by chronical aortic graft infection in a male with Loeys-Dietz syndrome: A case report

RATIONALE

Glomerulonephritis triggered by a chronically infected graft is increasingly identified because of widely used implanted device. Removal of the aortic graft and sustained antibiotic therapy is the usual approach to maximize the chance of renal recovery, but as this case shows graft removal is not always possible.

PATIENT CONCERNS

A 35-year-old man with intractable and recurrent fever had acute renal failure in sustained antibiotic therapy.

DIAGNOSES

Renal biopsy suggested crescentic glomerulonephritis. fluorodeoxyglucose/positron emission tomography-computed tomography showed increased metabolic activity at the site of aortic graft, reminding that chronic infection of an implanted graft can lead to severe glomerulonephritis. TGFBR2 c.1133G>T mutation was observed in mutation analysis, which was reported to be associated with Loeys-Dietz syndrome.

INTERVENTIONS

Although infection was properly controlled with appropriate antimicrobial treatment, his renal dysfunction did not improve. A short-term inclusion of low-dose corticosteroid significantly benefit without introducing harm.

OUTCOMES

He partly recovered from renal injury.

LESSONS

In patients with glomerulonephritis triggered by a long-duration infection, low-dose corticosteroid therapy may be considered when renal dysfunction secondary to nephritis does not improve after appropriate antimicrobial treatment.

Plasmapheresis and corticosteroids in infective endocarditis-related crescentic glomerulonephritis

Infective endocarditis (IE)-related glomerulonephritis (GN) typically resolves with the treatment of IE. A 59-year-old woman with a baseline creatinine of 0.7 mg/dL presented with rash on her legs, night sweats and weight loss for 3 weeks. Further evaluation revealed IE. Her blood cultures grew gamma-haemolytic streptococcus, which subsequently cleared on appropriate antibiotic therapy. Her creatinine, however, progressively worsened requiring haemodialysis. Kidney biopsy showed immune complex-mediated necrotising and crescentic GN. She was started on plasmapheresis (PE) and high-dose steroids with rapid taper, with subsequent improvement in her creatinine to 0.8 mg/dL. She subsequently had aortic valve replacement and ventricular septal defect closure. She did not improve as expected with antibiotic therapy but turned around dramatically with steroids and PE. Our case supports the possible beneficial role of PE and steroids in IE-related crescentic GN that worsens despite appropriate antibiotic therapy, although the risks of immunosuppression and aggravating endocarditis need to be considered.

Necrotizing Crescentic Glomerulonephritis Complicating Bivalvular Bacterial Endocarditis

In the setting of an increasing incidence of endocarditis in the United States, we report a patient with necrotizing crescentic glomerulonephritis (GN) associated with native valve bacterial endocarditis due to Streptococcus parasanguinis. He was started on appropriate antibiotic treatment and subsequent blood cultures showed no growth. However, due to continuing decline in kidney function, immunosuppressive therapy was started. Despite immunosuppressive therapy and antibiotics, renal function did not improve and chronic hemodialysis was required. Due to rarity of condition, there are no definite treatment guidelines available. Antibiotics, steroids, immunosuppressive agents can be of help in most cases. Further research in this regard may help with early diagnosis and better treatment modalities.

Bartonella Endocarditis and Pauci-Immune Glomerulonephritis: A Case Report and Review of the Literature

Among culture-negative endocarditis in the United States, Bartonella species are the most common cause, with Bartonella henselae and Bartonella quintana comprising the majority of cases. Kidney manifestations, particularly glomerulonephritis, are common sequelae of infectious endocarditis, with nearly half of all Bartonella patients demonstrating renal involvement. Although a pauci-immune pattern is a frequent finding in infectious endocarditis-associated glomerulonephritis, it is rarely reported in Bartonella endocarditis. Anti-neutrophil cytoplasmic antibody (ANCA) positivity can be seen with many pathogens causing endocarditis and has been previously reported with Bartonella species. In addition, ANCA-associated vasculitis can also present with renal and cardiac involvement, including noninfectious valvular vegetations and pauci-immune glomerulonephritis. Given the overlap in their clinical presentation, it is difficult to differentiate between Bartonella endocarditis and ANCA-associated vasculitis but imperative to do so to guide management decisions. We present a case of ANCA-positive Bartonella endocarditis with associated pauci-immune glomerulonephritis that was successfully treated with medical management alone.

ANCA positivity in a patient with infective endocarditis-associated glomerulonephritis: a diagnostic dilemma

Glomerulonephritis (GN) is an immunological phenomenon in bacterial endocarditis. These may be pauci-immune/vasculitic GN, post-infective GN, and sub-endothelial membranoproliferative glomerulonephritis. Each type of glomerulonephritis usually occurs in isolation. We report a case of infective endocarditis with dual existence of pauci-immune/vasculitic GN and post infective type of GN at the same time.

Glomerular disease in patients with infectious processes developing antineutrophil cytoplasmic antibodies

To identify differences in treatment and outcome of various types of glomerulonephritis developing in the course of infections triggering antineutrophil cytoplasmic antibody (ANCA) formation, we analyzed published reports of 50 patients. Immunosuppressives were added to antibiotics in 22 of 23 patients with pauci-immune glomerulonephritis. Improvement was noted in 85% of 20 patients with information on outcomes. Death rate was 13%. Corticosteroids were added to antibiotics in about 50% of 19 patients with postinfectious glomerulonephritis. Improvement rate was 74%, and death rate was 26%. Two patients with mixed histological features were analyzed under both pauci-immune and post-infectious glomerulonephritis categories. In 9 patients with other renal histology, treatment consisted of antibiotics alone (7 patients), antibiotics plus immunosuppressives (1 patient), or immunosuppressives alone (1 patient). Improvement rate was 67%, permanent renal failure rate was 22%, and death rate was 11%. One patient with antiglomerular basement disease glomerulonephritis required maintenance hemodialysis. Glomerulonephritis developing in patients who became ANCA-positive during the course of an infection is associated with significant mortality. The histological type of the glomerulonephritis guides the choice of treatment. Pauci-immune glomerulonephritis is usually treated with addition of immunosuppressives to antibiotics.

Bacterial infection-related glomerulonephritis in adults

In the past, most cases of bacterial infection-related glomerulonephritis (IRGN) occurred in children following streptococcal upper respiratory tract or skin infections and were called postinfectious GN. Over the past 3 decades, there has been an important shift in epidemiology, bacteriology, and outcome of IRGN. A significant percentage of cases now target adults, particularly the elderly or immunocompromised. Because adult infections are often ongoing at the time of diagnosis, the term IRGN appears more appropriate. The sites of infection in adult IRGN are more heterogeneous than in children, and include the upper respiratory tract, skin, lung, heart, urinary tract, teeth/oral mucosa, and bone. In adults, the disease is more likely to be secondary to non-streptococcal infections, particularly staphylococcal infection. In contrast to the favorable course in children, a significant proportion of adults with IRGN, especially the elderly and diabetics, do not recover renal function. Whereas the pathogenesis of post-streptococcal glomerulonephritis has been studied extensively, leading to the identification of two candidate nephritogenic streptococcal antigens, glyceraldehyde-3-phosphate dehydrogenase and pyrogenic exotoxin B, few investigations have focused on IRGN caused by other bacteria. This review will address the current status of sporadic bacterial IRGN in adults.

Membranoproliferative glomerulonephritis complicating Propionibacterium acnes infection

Background

Propionibacterium acnes (P. acnes) is a common microbe of the skin and mucosal surfaces rarely considered a true pathogen. However, it has been reported to cause serious infections. Subsequent ongoing low-grade antigenaemia may, in turn, lead to an immune-mediated glomerulonephritis with various renal histologies including that of membranoproliferative glomerulonephritis (MPGN).

Methods

Here, we describe two cases of P. acnes infection-induced MPGN and their treatment.

Results

Both patients were successfully treated by the eradication of the infection. One patient also received immunosuppressive medication prior to the correct diagnosis.

Conclusions

A vigorous exclusion of infection is warranted in MPGN type I or immune-complex-mediated MPGN and may sometimes yield a diagnosis of secondary MPGN.

Infective endocarditis associated with acute renal failure: Repeat renal biopsy and successful recovery

Infective endocarditis (IE) is a serious disease with a high associated mortality rate, particularly when complicated by acute renal failure (ARF). Although valve surgery and treatment with antibiotic agents are recommended, surgical options and the optimal therapy are not as yet well documented. Here, we report a rare case of IE in a young man with a history of intravenous drug abuse, who presented with high fever, bilateral thoracalgia, lower limb edema and renal dysfunction. After treatment with antibiotics, hemodialysis and anticoagulants, a tricuspid valve replacement surgery was performed on the patient. After surgery, his renal functions deteriorated and progressed to ARF. The first renal biopsy showed type II crescentic glomerulonephritis. After receiving continuous ambulatory peritoneal dialysis followed by administration of an angiotensin converting enzyme inhibitor and angiotensin receptor blockers, the patient's serum creatinine level decreased and the urine output increased gradually. In order to identify the renal turnover, we performed a second biopsy and found significant improvement in the pathological changes with endocapillary proliferative glomerulonephritis and fibrous crescents. Successful recovery of renal function was achieved 12 weeks after the initiation of therapy. Therefore, eradication of infection, tricuspid valve replacement and renal substitution therapy may be sufficient in some cases.

Propionibacterium endocarditis: A case series from the International Collaboration on Endocarditis Merged Database and Prospective Cohort Study

Propionibacterium species are occasionally associated with serious systemic infections such as infective endocarditis. In this study, we examined the clinical features, complications and outcome of 15 patients with Propionibacterium endocarditis using the International Collaboration on Endocarditis Merged Database (ICE-MD) and Prospective Cohort Study (ICE-PCS), and compared the results to 28 cases previously reported in the literature. In the ICE database, 11 of 15 patients were male with a mean age of 52 y. Prosthetic valve endocarditis occurred in 13 of 15 cases and 3 patients had a history of congenital heart disease. Clinical findings included valvular vegetations (9 patients), cardiac abscesses (3 patients), congestive heart failure (2 patients), and central nervous system emboli (2 patients). Most patients were treated with beta-lactam antibiotics alone or in combination for 4 to 6 weeks. 10 of the 15 patients underwent valve replacement surgery and 2 patients died. Similar findings were noted on review of the literature. The results of this paper suggest that risk factors for Propionibacterium endocarditis include male gender, presence of prosthetic valves and congenital heart disease. The clinical course is characterized by complications such as valvular dehiscence, cardiac abscesses and congestive heart failure. Treatment may require a combination of medical and surgical therapy.

Chronic prosthetic valve endocarditis due to Propionibacterium acnes: an unexpected cause of prosthetic valve dysfunction

INTRODUCTION AND OBJECTIVES

To determine the characteristics of Propionibacterium acnes prosthetic valve endocarditis (PAPVE).

METHODS

Prospective descriptive study of 16 consecutive cases of PAPVE.

RESULTS

Seven patients developed PAPVE early and 9 developed it late. In all those who developed PAPVE late, there was a history of mucocutaneous barrier manipulation. The delay in diagnosis was >3 months in 75%. The clinical presentation was asymptomatic prosthetic valve dysfunction in 31%, heart failure in 19%, coronary syndrome in 12.5%, fever in 25%, and neurological deficits in 19%. At diagnosis, 62.5% had heart failure and 44% had fever. The predominant echocardiographic finding was prosthesis dysfunction due to dehiscence of metallic aortic valves (6 out of 7) or stenosis of metallic mitral valves (4 out of 7). In 2 of the 3 biological aortic prostheses, dysfunction was due to leaflet distortion. Blood cultures and surgical specimens tested positive after a mean of 11.6 and 12.2 days, respectively. In 2 cases, the diagnosis was confirmed by PCR. The principle intraoperative finding was the presence of abundant grayish pannus. Histology demonstrated the absence of acute inflammatory features. Twelve patients received antibiotic treatment with valve replacement: 7 were cured, 4 experienced early prosthesis dehiscence and 1 relapsed. All 3 patients who were initially treated with antibiotics alone suffered relapses.

CONCLUSIONS

Generally, PAPVE presents as prosthetic valve dysfunction with few symptoms of infection. Prolonged incubation of cultures is essential for diagnosis. Antibiotic treatment provides clinical control but does not eradicate the infection, and valve replacement is necessary for a cure. The postoperative course can be complicated by prosthesis dehiscence.

Infective endocarditis due to Propionibacterium species

Propionibacterium species rarely cause infective endocarditis. When identified in blood cultures, they may be inappropriately disregarded as skin flora contaminants. The purpose of this study was to characterize the clinical presentation and management of endocarditis due to Propionibacterium species. All cases of endocarditis due to Propionibacterium species that were treated at the Mayo Clinic, Rochester, USA were retrospectively reviewed, and the English language medical literature was searched for all previously published reports. Seventy cases, which included eight from the Mayo Clinic, were identified (clinical details were available for only 58 cases). The median age of patients was 52 years, and 90% were males. In 79% of the cases, the infection involved prosthetic material (39 prosthetic valves, one left ventricular Teflon patch, one mitral valve ring, one pulmonary artery prosthetic graft, three pacemakers, and one defibrillator). Blood cultures were positive in 62% of cases. All 22 cases with negative blood cultures were microbiologically confirmed by either positive valve tissue cultures (n = 21) or molecular methods (n = 1). Endocarditis was complicated by abscess formation in 36% of cases. The majority (81%) of patients underwent surgery, either for valve replacement and debridement of a cardiac abscess, or removal of an infected device. Crude in-hospital mortality was 16%. The median duration of postoperative antibiotic treatment was 42 days. Patients were commonly treated with a penicillin derivative alone or in combination with gentamicin. On the basis of the above data, it is recommended that infective endocarditis should be strongly suspected when Propionibacterium species are isolated from multiple blood cultures, particularly in the presence of a cardiovascular device.

Rapidly progressive glomerulonephritis associated with nontuberculous mycobacteria

A 72-year-old woman with a past medical history of nontuberculous mycobacteria (NTM) pulmonary disease was admitted because of hemoptysis and acute renal failure. A chest X-ray showed interstitial infiltration over bilateral lung fields. Kidney biopsy showed immune complex-mediated acute diffuse proliferative glomerulonephritis with 48% crescents and glomerular endocapillary hypercellularity with exudative neutrophils suggestive of infection-related glomerulonephritis. Reactivated NTM infection of the lungs was suspected when mycobacterial cultures of the sputum repeatedly yielded Mycobacterium avium. A lung biopsy revealed chronic inflammation without evidence of alveolar capillaritis. A diagnosis of NTM pulmonary disease was further confirmed by tissue culture of the lung biopsy specimens. Antituberculous drugs in combination with clarithromycin were given for the treatment of NTM infection. Pulmonary symptoms promptly responded to the treatments. Furthermore, renal function steadily improved after initiation of anti-NTM therapy. To our knowledge, this is the first report of rapidly progressive glomerulonephritis associated with NTM infection.

Endocarditis caused by Propionibacterium species: a report of three cases and a review of clinical features and diagnostic difficulties

Propionibacterium species are members of the normal flora of skin and the mouth but their pathogenic potential is often overlooked. Three fatal cases of endocarditis caused by Propionibacterium species over an 8-year period are reported, and a review is presented of a further 33 cases from the world literature. In most cases, infection was protracted, with minimal signs in the early stages. Fourteen cases (42.4%) involved native valves, 16 (48.5%) involved prosthetic valves and three (9.1%) were associated with other intracardiac prosthetic material. Intracardiac abscesses were commonly encountered, with Propionibacterium endocarditis occurring in 28.6% of native valve infections and 52.9% of prosthetic valve infections. A very high proportion of all of the cases (70.6%) required surgical intervention. Several factors appeared to delay institution of appropriate therapy and may have contributed to abscess formation, including an indolent clinical course, negative or delayed culture results, and the tendency to consider this organism as a blood-culture contaminant. The authors recommend careful clinical evaluation before disregarding a blood-culture isolate of Propionibacterium spp. as a skin contaminant, and consideration of this bacterium as a potential cause of apparently culture-negative endocarditis.