Complements do not lie.
A 74-year-old patient presented with constitutional symptoms and was found to have acute kidney injury. He was known to have a prosthetic aortic valve. He was febrile with splenomegaly and vasculitic lesions on both hands. Nephritic screen revealed strongly positive cytoplasmic-antineutrophil cytoplasmic antibodies (c-ANCA). Differential diagnosis thus included a small vessel vasculitis or infective endocarditis. Transoesophageal echocardiography demonstrated no vegetations and serial blood cultures were negative. Immunosuppression for presumed granulomatosis with polyangiitis (Wegeners granulomatosis) was therefore instituted. The patient deteriorated, requiring multi-organ support. Renal biopsy showed a proliferative glomerulopathy and complements were low. Atypical screen for culture negative endocarditis revealed a strongly positive IgG-antibody titre against Bartonella henselae. Immunosuppression was discontinued and treatment for chronic Bartonellosis commenced. The patient made a remarkable recovery. His renal function quickly returned to normal, and ANCA titres and complements normalised. He was discharged home after completing a 6 week course of antibiotic therapy.
ICU, Barts and the London NHS Trust, London, UK. sterob67@hotmail.com
Stefanie Christina
SC
Robert
Suzanne Helen
SH
Forbes
Surusch
S
Soleimanian
Julia S
JS
Hadley
D058186:Acute Kidney Injury / Q000150:complications; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D056648:Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis / Q000175:diagnosis*; D019268:Antibodies, Antineutrophil Cytoplasmic / Q000097:blood; D018416:Bartonella henselae; D003176:Complement C3 / Q000378:metabolism; D003181:Complement C4 / Q000378:metabolism; D003937:Diagnosis, Differential; D004697:Endocarditis, Bacterial / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology*; D006801:Humans; D008297:Male
D000900:Anti-Bacterial Agents; D019268:Antibodies, Antineutrophil Cytoplasmic; D003176:Complement C3; D003181:Complement C4