title: Vasculitic purpura with antineutrophil cytoplasmic antibody-positive acute renal failure in a patient with Streptococcus bovis case and Neisseria subflava bacteremia and subacute endocarditis.
abstract: Subacute bacterial endocarditis is frequently associated with extracardiac manifestations and renal failure. Clinical variety of endocarditis manifestation is wide and has the potential to mimic vasculitis. Whereas Streptococcus bovis is often isolated and associated with colonic tumors, Neisseriaceae are rarely found. An association of subacute bacterial endocarditis and antineutrophil cytoplasmic antibodies has been described. We report on a 62-year-old man who was admitted to our hospital with acute oliguric renal failure and a nonpruritic purpural rush without fever. Antineutrophil cytoplasmic antibody diagnostic revealed perinuclear staining with a titre of 1 : 512 and antiproteinase-3 specificity. Immune complex-mediated glomerulonephritis without extracapillary proliferation was diagnosed in renal biopsy. Finally, blood cultures became positive for Streptococcus bovis and Neisseria flava. Echocardiography showed mobile vegetations on tricuspid valve. Under treatment with penicillin G and gentamicin, skin efflorescences and renal function recovered, but vegetations increased. A colonic tumor could be excluded, a disastrous dental status may have been a predisposal factor. When classical findings of subacute bacterial endocarditis are less clear, the presence of renal failure and antineutrophil cytoplasmic antibodies in absence of fever may lead to misdiagnosis and deleterious immunosuppressive therapy. Neisseria subflava, an upper respiratory tract commensal, may cause subacute bacterial endocarditis without typical symptoms.
authors.affiliation: Department of Medicine I, University of Lübeck School of Medicine, Lübeck, Germany. bauer-alex@gmx.de
authors.forename: A
authors.initials: A
authors.lastname: Bauer
authors.forename: W J
authors.initials: WJ
authors.lastname: Jabs
authors.forename: S
authors.initials: S
authors.lastname: Süfke
authors.forename: M
authors.initials: M
authors.lastname: Maass
authors.forename: B
authors.initials: B
authors.lastname: Kreft
mesh_terms: D058186:Acute Kidney Injury / Q000150:complications* / Q000276:immunology*; D019268:Antibodies, Antineutrophil Cytoplasmic / Q000032:analysis / Q000276:immunology*; D016470:Bacteremia / Q000150:complications*; D004698:Endocarditis, Subacute Bacterial / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016870:Neisseriaceae Infections / Q000150:complications*; D011693:Purpura / Q000150:complications*; D013290:Streptococcal Infections / Q000150:complications*; D016985:Streptococcus bovis; D014657:Vasculitis / Q000150:complications*
chemical_list: D019268:Antibodies, Antineutrophil Cytoplasmic