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Abstract: PO1616

Infective Endocarditis Associated Pauci-Immune GN: Look Before You Leap

Session Information

Category: Glomerular Diseases

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Pavlovich, Stephanie S., University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States
  • Bennett, William Cannon, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States
  • Terinte-Balcan, George, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States
  • Hladik, Gerald A., University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States
  • Jain, Koyal, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States
Introduction

Small vessel vasculitis has a broad array of potential etiologies. A patient with known cryoglobulinemia due to hepatitis C (HCV) presenting with fever, glomerular hematuria and leukocytoclastic vasculitis because of endocarditis illustrates the importance of a judicious diagnostic evaluation.

Case Description

41-year-old male with a history of HCV and intravenous drug use presented with confusion, migratory arthralgias and receptive aphasia over 3 months. 1 month prior to admission he was diagnosed with HCV-related type III cryoglobulinemia and started on therapy with glecaprevir/pibrentasvir. On exam he had a temperature of 38.4°C, petechial rash, receptive aphasia and systolic murmur. Laboratory data showed creatinine 1.23mg/dL, CRP 45.1mg/L, rheumatoid factor 15.9 IU/mL, type III cryoglobulins, PR3-ANCA 49.6U/mL and normal complement levels. Skin biopsy showed leukocytoclastic vasculitis. MRI of the brain showed foci of hemosiderin deposition consistent with vasculitic lesions. Blood cultures grew E. faecalis and echocardiogram showed a mitral valve vegetation. Kidney biopsy showed pauci-immune necrotizing GN and diffuse ATN. As creatinine worsened (peak 2.66mg/dL), mycophenolate (MMF) was added after resolution of bacteremia following iv antibiotics. 1 week after stopping antibiotics, he was readmitted with AKI, nephritic syndrome, and recurrent E. fecalis bacteremia. MMF was stopped and antibiotics restarted with improvement in creatinine (1.40mg/dL) and urine sediment.

Discussion

This is a rare case of PR3-ANCA vasculitis due to E. faecalis endocarditis. A kidney biopsy and high index of suspicion is crucial in diagnosing pauci-immune GN in patients with preexisting vasculitis. Absence of hypocomplementemia raised suspicion for a superimposed process. This case highlights the importance of a careful evaluation in patients presenting with vasculitis despite appropriate treatment of a preexisting vasculitic syndrome.