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Kidney Week

Abstract: TH-PO135

First Case of Leptotrichia goodfellowii Endocarditis-Associated Glomerulonephritis

Session Information

Category: Trainee Case Report

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Kochar, Guneet S., Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Herron, Ann, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Burgner, Anna Marie, Vanderbilt University Medical Center, Nashville, Tennessee, United States
Introduction

Infective endocarditis is a well described cause of glomerulonephritis (GN), but can be difficult to diagnose. We present the first case of ANCA-associated immune complex GN from Leptotrichia goodfellowii endocarditis with initial diagnosis made by kidney biopsy.

Case Description

A 57 year old male with hypertrophic cardiomyopathy with an ICD was found to have an acute rise of his creatinine to 3.4 mg/dL from a baseline of 1.1 mg/dL prior to his left heart catheterization in preparation for a septal myectomy. He noted two weeks of lower extremity edema, chills, subjective fevers, and poor oral intake. Workup notable for a UPCR 1.9 mg/mg, 415 RBC/HPF with dysmorphic RBCs, low C3 and C4 at 35 and 8 mg/dL respectively, atypical ANCA staining with positive MPO and PR3, and type II cryoglobulinemia. Remainder of serologic workup was negative. Creatinine worsened so methylprednisolone 1 gram daily was started and a renal biopsy was performed showing IgM dominant, predominantly mesangiopathic immune complex and necrotizing crescentic glomerulonephritis suggestive of endocarditis, as well as diffuse tubular injury. He developed acute severe mitral valve regurgitation due to a torn chordal tissue with vegetations seen on the mitral valve and an ICD lead. He was started on broad spectrum antibiotics and steroids stopped. Blood cultures grew Leptotrichia goodfellowii, likely from recent dental work, and antibiotics narrowed to ceftriaxone and metronidazole with subsequently cleared blood cultures. He required initiation of hemodialysis a week after his biopsy, but after completing antibiotic treatment, he had renal function recovery allowing stoppage of hemodialysis after two months with most recent creatinine 1.9 mg/dL.

Discussion

To our knowledge, this is the first reported case of endocarditis-associated GN from Leptotrichia goodfellowii, a gram negative fusiform bacteria found in oral flora. It highlights the importance of considering indolent infectious etiologies in patients with acute renal failure. Clues suggesting subacute endocarditis-associated GN include presence of cardiac devices, low C3 and C4, and ANCA positivity, though kidney biopsy is key in confirming the diagnosis. While the role of immunosuppression in these patients is unclear, renal recovery can be seen with antimicrobial therapy alone, underscoring the need for isolation of the pathogen.