Cervi Andrea, Kelly Dylan, Alexopoulou Iakovina, Khalidi Nader
Internal Medicine Residency Program.
Department of Pathology and Molecular Medicine, and.
Clin Nephrol Case Stud. 2017 Apr 26;5:32-37. doi: 10.5414/CNCS109076. eCollection 2017.
We report the case of a 59-year-old man with chronic hepatitis B and C infection presenting with acute kidney injury and enterococcus faecalis-infective endocarditis (IE). An elevated proteinase-3 (PR3)-ANCA and pauci-immune glomerulonephritis (GN) on renal biopsy were discovered, corresponding to ANCA-mediated GN. We conducted a literature review to assess the role of ANCA in IE and treatment implications.
On systematic review of the literature, we found five previous cases whereby IE caused by streptococcus and bartonella species were related to ANCA vasculitis-associated GN.
Most reports of IE-related GN are mediated by immune complex deposition and resolve following microbial clearance. Of the 5 cases of ANCA GN in the setting of IE, all had markedly elevated levels of PR3-ANCA with either a subacute or chronic course of infection. Patients were treated with a combination of steroids and cyclophosphamide (2/5), steroids and antibiotics alone (1/5), or with valvular replacement (2/5). Renal function was recovered in 4/5 patients.
Infection is a major etiologic player in the formation of ANCA; however, the role of PR3-ANCA in IE remains unclear. Kidney biopsy is essential in differentiating IE-related GN due to infection and immune complex deposition versus ANCA-associated vasculitis. A paucity of reports on the development of GN in IE-associated ANCA vasculitis exists, highlighting the rarity of our case and lack of clear therapeutic strategies in a patient with active infection requiring immunosuppression. In this case, the patient's chronic hepatitis B and C coinfection presented a unique challenge.
我们报告一例59岁慢性乙型和丙型肝炎感染男性患者，其出现急性肾损伤和粪肠球菌感染性心内膜炎（IE）。肾活检发现蛋白酶3（PR3）-抗中性粒细胞胞浆抗体（ANCA）升高及寡免疫性肾小球肾炎（GN），符合ANCA介导的GN。我们进行了文献综述，以评估ANCA在IE中的作用及治疗意义。
通过对文献的系统回顾，我们发现此前有5例由链球菌和巴尔通体属引起的IE与ANCA血管炎相关的GN有关。
大多数IE相关GN的报告是由免疫复合物沉积介导的，在微生物清除后可缓解。在IE背景下的5例ANCA GN病例中，所有患者的PR3-ANCA水平均显著升高，感染病程为亚急性或慢性。患者接受了类固醇和环磷酰胺联合治疗（2/5）、仅接受类固醇和抗生素治疗（1/5）或接受瓣膜置换治疗（2/5）。4/5的患者肾功能恢复。
感染是ANCA形成的主要病因；然而，PR3-ANCA在IE中的作用仍不清楚。肾活检对于区分由感染和免疫复合物沉积引起的IE相关GN与ANCA相关血管炎至关重要。关于IE相关ANCA血管炎中GN发生的报告较少，凸显了我们病例的罕见性以及在需要免疫抑制的活动性感染患者中缺乏明确的治疗策略。在本病例中，患者慢性乙型和丙型肝炎合并感染带来了独特的挑战。
