Bartonellaendocarditis masquerading as systemic vasculitis with rapidly progressive glomerulonephritis (aka ‘Löhlein nephritis’)

Abstract

Bartonella species are fastidious, Gram-negative aerobic rods and a well-recognised pathogen responsible for culture-negative endocarditis. The histopathological appearance of glomerulonephritis (GN) caused by Bartonella endocarditis may include a pauci-immune GN similar to that usually seen in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Herein, we present an unusual case report of Bartonella endocarditis masquerading as ANCA-positive vasculitis, with crescentic GN. A 66-year-old woman, who had undergone aortic valve replacement 2 years prior to admission, presented with confusion and loss of vision in her right nasal field. Following an extensive diagnostic evaluation, the main findings were right central retinal artery occlusion, ground-glass appearance on chest CT and ANCA-positive, anti PR-3 negative, rapidly progressive GN. The patient was scheduled to start treatment with rituximab for presumed ANCA-positive GN, when a positive serological test for Bartonella henselae was received. In view of this result, a diagnosis of endocarditis was made, based on fulfilment of five Duke minor criteria, namely fever, predisposition, arterial emboli, immunological phenomena and serological evidence of active infection with an organism consistent with infective endocarditis. Immunosuppressive treatment was withheld and antibiotic treatment initiated. This case report emphasises the need for maintaining a high index of suspicion regarding the diagnosis of Bartonella infection, which might mimic ANCA-associated GN.

A case of Bartonella henselae native valve endocarditis presenting with crescentic glomerulonephritis

“…Post-antimicrobial mitral valve replacement for continued deterioration and continued evidence of mycotic aneurysm. Retreated with 2 weeks of Gentamicin plus Doxycycline and 4 weeks of Doxycycline Not reported [24] 66 yo female Yes Yes, bioprosthetic aortic valve Negative TEE, but fulfilled all five conditions for modified Duke minor criteria Crescentic glomerulonephritis, Right central retinal artery occlusion, leukopenia & thrombocytopenia Multiple sets negative B. henselae 1:1600 MultipleANA 1:320, Positive RF, c-ANCA positive Bartonella PCR testing on kidney biopsy tissue negative Not applicable 2 weeks of Gentamicin and 4 months of Doxycycline, until titer decreased to 1:400. Almost started on Rituximab, in addition to steroids prior to return of positive B. henselae titer [25] Male Yes Yes, bicuspid aortic valve with two separate aortic valve replacements Bioprosthetic aortic valve Acute renal failure, two aneurysmal hemorrhagic stroke, eventually heart failure Several negative B. henselae IgG 1:> /= 1024, IgM 1:20 None DNA PCR positive initially, negative subsequently.…”

A case of Bartonellosis presenting as a puzzling multisystem disorder complicated by nosocomial COVID-19 infection

“…Unfortunately, renal histology is not available to confirm the presence of glomerulonephritis but this has been commonly reported in Bartonella including the absence of endocarditis. 4 5 …”

Clinical Manifestations Associated with Bartonella henselae Infection in a Tropical Region

“…Similar to our two endocarditis cases, there have been at least 58 case reports documenting B. henselae infection-related glomerulonephritis presenting with a variety of clinical, laboratory, and histological features mimicking vasculitic glomerulonephritis including 12 cases published in the last 5 years. [25][26][27][28][29][30][31][32][33][34][35][36] One notable nonendocarditis case ended up losing a renal allograft as a result. 35 Diagnoses of bartonellosis in many of these cases were often made on incidental finding of concurrent culturenegative endocarditis, and in a significant number of cases, an earlier diagnosis could have avoided unnecessary immunosuppression, hence highlighting the need to consider Bartonella or endocarditis-related glomerulonephritis as a differential diagnosis in our population presenting with atypical features of glomerulonephritis or vasculitis.…”