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Kidney Week

Abstract: TH-PO115

Renal Dysfunction in Bartonella Endocarditis With ANCA Positive Titers: A Management Dilemma

Session Information

  • AKI: Mechanisms - I
    November 03, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
    Abstract Time: 10:00 AM - 12:00 PM

Category: Acute Kidney Injury

  • 103 AKI: Mechanisms

Authors

  • Rajmohan, Tharika S., Mercy Fitzgerald Hospital, Darby, Pennsylvania, United States
  • Sreemantula, Harsha Sai, Mercy Fitzgerald Hospital, Darby, Pennsylvania, United States
  • Chaudhry, O'Neil Parkinson, Mercy Fitzgerald Hospital, Darby, Pennsylvania, United States
  • Hanif, Muhammad Owais, Mercy Fitzgerald Hospital, Darby, Pennsylvania, United States
  • Mcclure, Charles Patrick, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
Introduction

Bartonella endocarditis is the common cause of culture-negative endocarditis. Renal dysfunction is common in infective endocarditis with immune complex mediated Glomerunephritis (GN). Here we discuss a case of acute kidney injury in Bartonella endocarditis with elevated anti neutrophil cytoplasmic antibodies (ANCA) which makes the management complex.

Case Description

60-year-old homeless male with history of recurrent upper gastrointestinal(GI) bleeds from arteriovenous malformation, anemia of chronic disease, ischemic cardiomyopathy (ejection fraction of 45%) with defibrillator placement, mitral regurgitation, hypertension, chronic hepatitis B treated, pulmonary embolism not on any anticoagulation due to GI bleed, polysubstance abuse from cocaine and alcohol, presented with complaints of malaise, fatigue and shortness of breath on exertion. Physical examination was remarkable for pale conjunctiva, and holosystolic murmur heard at the apex. Vitals were unremarkable. Labs were remarkable for hemoglobin of 6.9 mg/dL, platelet count of 30,000 and creatinine (Cr) of 6.10 mg/dL (baseline creatinine of 1 mg/dL, 3 months ago). Urinalysis was suggestive of significant proteinuria of >300 mg/dl, Blood +ve with RBC and a normal renal scan. Renal panel showed low complements with positive ANCA titers with proteinase 3 (PR3) along with positive Rheumatoid Factor. Echocardiogram showed vegetation with Bartonella serology positive. Renal Biopsy was placed on hold due to thrombocytopenia and anitbiotics was started (Doxyxcycline and Rifampin). He required hemodialysis due to worsening acidosis and significant uremia and later died due to disseminated intravscular coagulation and septic shock.

Discussion

Presence of ANCA positive titers in a culture negative Bartonella endocarditis renal dysfunction is an interesting and challenging at the same time as ANCA vasculitis traditionally is Pauci immune on immunoflouresence with normal complements. Renal dysfunction with hypocomplementemia in an immune complex glomerulonephritis (GN) and positive ANCA titers creates confusion as management can be challenging with antibiotics as the mainstay for the treatment of endocarditis, while immunosuppression is for ANCA vasculitis. Few case reports have been reported where renal biopsy plays a major role in terms of management.