Culture negative endocarditis combined with glomerulonephritis caused by Bartonella species in two immunocompetent adults

Clinicopathological differences between Bartonella and other bacterial endocarditis-related glomerulonephritis - our experience and a pooled analysis

Background

Although Staphylococcus aureus is the leading cause of acute infective endocarditis (IE) in adults, Bartonella spp. has concomitantly emerged as the leading cause of "blood culture-negative IE" (BCNE). Pre-disposing factors, clinical presentation and kidney biopsy findings in Bartonella IE-associated glomerulonephritis (GN) show subtle differences and some unique features relative to other bacterial infection-related GNs. We highlight these features along with key diagnostic clues and management approach in Bartonella IE-associated GN.

Methods

We conducted a pooled analysis of 89 cases of Bartonella IE-associated GN (54 published case reports and case series; 18 published conference abstracts identified using an English literature search of several commonly used literature search modalities); and four unpublished cases from our institution.

Results

Bartonella henselae and Bartonella quintana are the most commonly implicated species causing IE in humans. Subacute presentation, affecting damaged native and/or prosthetic heart valves, high titer anti-neutrophil cytoplasmic antibodies (ANCA), mainly proteinase-3 (PR-3) specificity, fastidious nature and lack of positive blood cultures of these Gram-negative bacilli, a higher frequency of focal glomerular crescents compared to other bacterial infection-related GNs are some of the salient features of Bartonella IE-associated GN. C3-dominant, but frequent C1q and IgM immunofluorescence staining is seen on biopsy. A "full-house" immunofluorescence staining pattern is also described but can be seen in IE -associated GN due to other bacteria as well. Non-specific generalized symptoms, cytopenia, heart failure and other organ damage due to embolic phenomena are the highlights on clinical presentation needing a multi-disciplinary approach for management. Awareness of the updated modified Duke criteria for IE, a high index of suspicion for underlying infection despite negative microbiologic cultures, history of exposure to animals, particularly infected cats, and use of send-out serologic tests for Bartonella spp. early in the course of management can help in early diagnosis and initiation of appropriate treatment.

Conclusion

Diagnosis of IE-associated GN can be challenging particularly with BCNE. The number of Bartonella IE-associated GN cases in a single institution tends to be less than IE due to gram positive cocci, however Bartonella is currently the leading cause of BCNE. We provide a much-needed discussion on this topic.

Bartonella henselae Infective Endocarditis: A Rare Cause of Pauci-Immune Necrotizing Glomerulonephritis-A Case Report

Rationale

Bartonella sp. are the most common causes of culture-negative infective endocarditis (IE) cases in the United States. Although, infection-related glomerulonephritis can frequently mimic primary vasculitis due to pauci-immune pattern, majority of previously reported cases of Bartonella henselae-associated glomerulonephritis have immune-complex deposits on immunofluorescence. We present a rare case of B henselae IE-related pauci-immune necrotizing glomerulonephritis. Timely recognition of this atypical presentation led to appropriately directed medical therapy.

Presenting concerns of the patient

A 33-year-old Caucasian male with a history of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART), alcohol abuse, previous subarachnoid hemorrhage (SAH), and recent wisdom tooth extraction (on amoxicillin) was transferred from an outside hospital for further evaluation of severe headache. He was diagnosed with an SAH and right anterior cerebral artery mycotic aneurysm. The serum creatinine at the outside hospital was 292 umol/L (3.3 mg/dL) with a previously normal baseline around 2 years ago. The serum creatinine at our institution was 256 umol/L (3.0 mg/dL). The urinalysis demonstrated +100 protein, +3 blood and 29 red blood cells/high power field. The urine protein creatinine ratio (UPC) was 1.7 g/g. Serologic evaluation was positive for a low C4 10.2 mg/dL, elevated rheumatoid factor 40 IU/mL and an elevated proteinase 3 (PR-3) antineutrophilic cytoplasmic antibodies (ANCA Ab) 4.0 U/mL. A transesophageal echocardiogram (TEE) showed echo densities on both mitral and aortic valve. Blood cultures were negative. Further serologic evaluation was positive for B henselae IgG titer of 1:2560 (normal <1:320) with a negative IgM titer.

Diagnoses

A percutaneous kidney biopsy revealed pauci-immune necrotizing glomerulonephritis, with 14/16 glomeruli globally sclerotic, and 2 glomeruli with active segmental necrotizing lesions. There was no evidence of immune-complex deposition on immunofluorescence or electron microscopy. Clinical findings were consistent with B henselae IE associated mycotic aneurysm and necrotizing glomerulonephritis.

Intervention

Empiric treatment for an active glomerulonephritis with immunosuppressive agents was deferred on admission, given concern for an underlying infectious process and mycotic aneurysms in an HIV-positive patient. He received antibiotic treatment with doxycycline and ceftriaxone with gentamicin for synergy. Despite this, the mitral and aortic valve regurgitation worsened, and he developed congestive heart failure requiring aortic valve replacement and mitral valve repair. The explanted aortic valve was positive for B henselae by polymerase chain reaction (PCR) confirming the diagnosis of B henselae IE.

Outcomes

Immunosuppression was deferred due to timely identification of an atypical presentation of B henselae-associated ANCA antibodies-positive, pauci-immune necrotizing glomerulonephritis. A course of antibiotic treatment resulted in improved renal functions along with undetectable B henselae and PR3 Ab titers. The serum creatinine decreased to 176 umol/L (2 mg/dL) and remained stable 12 months after discharge.

Teaching points

B henselae IE should be suspected in patients with pauci-immune necrotizing glomerulonephritis and culture-negative IE. This is imperative for optimal decision making in the management of such patients. Having high clinical suspicion can avoid unnecessary and potentially deleterious use of immunosuppressive agents.

Bartonella Endocarditis Mimicking Crescentic Glomerulonephritis with PR3-ANCA Positivity

Bartonella henselae is a fastidious organism that causes cat scratch disease, commonly associated with fever and lymphadenopathy but, in rare instances, also results in culture-negative infectious endocarditis. We describe a patient who presented with flank pain, splenic infarct, and acute kidney injury with an active urinary sediment, initially suspicious for vasculitis, which was subsequently diagnosed as B. henselae endocarditis. Bartonella endocarditis may present with a crescentic glomerulonephritis (GN) and elevated PR3-ANCA antibody titers, mimicking ANCA-associated GN, with 54 cases reported in the literature. Unique to our case in this series is a positive PR3-ANCA antibody despite a negative IIF-ANCA. Thus, the presentation of Bartonella can mimic ANCA-associated GN, and renal biopsy showing immune complex deposition is critical for diagnosis and appropriate treatment.

Bartonella Endocarditis and Pauci-Immune Glomerulonephritis: A Case Report and Review of the Literature

Among culture-negative endocarditis in the United States, Bartonella species are the most common cause, with Bartonella henselae and Bartonella quintana comprising the majority of cases. Kidney manifestations, particularly glomerulonephritis, are common sequelae of infectious endocarditis, with nearly half of all Bartonella patients demonstrating renal involvement. Although a pauci-immune pattern is a frequent finding in infectious endocarditis-associated glomerulonephritis, it is rarely reported in Bartonella endocarditis. Anti-neutrophil cytoplasmic antibody (ANCA) positivity can be seen with many pathogens causing endocarditis and has been previously reported with Bartonella species. In addition, ANCA-associated vasculitis can also present with renal and cardiac involvement, including noninfectious valvular vegetations and pauci-immune glomerulonephritis. Given the overlap in their clinical presentation, it is difficult to differentiate between Bartonella endocarditis and ANCA-associated vasculitis but imperative to do so to guide management decisions. We present a case of ANCA-positive Bartonella endocarditis with associated pauci-immune glomerulonephritis that was successfully treated with medical management alone.

Necrotizing ANCA-Positive Glomerulonephritis Secondary to Culture-Negative Endocarditis

Infective endocarditis (IE) and small-vessel vasculitis may have similar clinical features, including glomerulonephritis. Furthermore the association between IE and ANCA positivity is well documented, making differential diagnosis between IE- and ANCA-associated vasculitis particularly difficult, especially in case of culture-negative IE. We report on one patient with glomerulonephritis secondary to culture-negative IE caused by Bartonella henselae which illustrates this diagnostic difficulty.

Bartonella henselae endocarditis and glomerulonephritis with dominant C3 deposition in a 21-year-old male with a Melody transcatheter pulmonary valve: case report and review of the literature

We report a case of a 21-year-old young man with underlying congenital heart disease who developed Bartonella henselae endocarditis of the right ventricular outflow tract (RVOT) conduit of his Melody transcatheter (percutaneous) pulmonary valve (TPV), with an initial presentation of glomerulonephritis with a dominant C3 pattern, with renal failure and circulating cryoglobulins. There are few reports of a glomerulonephritis with a dominant C3 pattern presenting as a manifestation of B. henselae endocarditis. While most cases of B. henselae endocarditis affect the aortic valve, in this case the valve damage was to the RVOT of the Melody TPV, a percutaneous transcatheter valve delivery system that had previously replaced his pulmonary homograft, which had become dysfunctional as a result of prior Streptococcus viridans endocarditis. The pulmonary homograft had been in place since childhood as a result of a Ross procedure to repair his congenital aortic stenosis. The patient's renal failure significantly improved after surgical resection of the infected RVOT and institution of appropriate antibiotic therapy.

Culture negative endocarditis: a diagnostic and therapeutic challenge!

Infective endocarditis remains a diagnostic and therapeutic challenge. The authors report an older male who presented with a lower extremities rash and signs of cardiac failure. Echocardiography showed vegetations attached to the bio-prosthetic aortic valve, however, with negative blood cultures. Further investigation revealed positive Bartonella serologies. The patient was diagnosed with Bartonella endocarditis affecting the prosthetic valve and started on appropriate antibiotics. Valvular surgery was refused by patient secondary to age and medical co-morbidities. The patient presented 10 days later with intracerebral haemorrhage and progression of the endocarditis as demonstrated on echocardiogram. Valve replacement was contraindicated at this occasion due to the intracerebral bleed. The patient had poor prognosis and a decision to withdraw care was made by the family. The authors demonstrate a case of complicated infective endocarditis caused by Bartonella species leading to multisystem involvement. This case highlights the need for urgent valve replacement in the setting of Bartonella endocarditis.

Bartonella and intraocular inflammation: a series of cases and review of literature

PURPOSE

To present various forms of uveitis and/or retinal vasculitis attributed to Bartonella infection and review the impact of this microorganism in patients with uveitis.

METHODS

Retrospective case series study. Review of clinical records of patients diagnosed with Bartonella henselae and Bartonella quintana intraocular inflammation from 2001 to 2010 in the Ocular Inflammation Department of the University Eye Clinic, Ioannina, Greece. Presentation of epidemiological and clinical data concerning Bartonella infection was provided by the international literature.

RESULTS

Eight patients with the diagnosis of Bartonella henselae and two patients with B. quintana intraocular inflammation were identified. Since four patients experienced bilateral involvement, the affected eyes totaled 14. The mean age was 36.6 years (range 12-62). Uveitic clinical entities that we found included intermediate uveitis in seven eyes (50%), vitritis in two eyes (14.2%), neuroretinitis in one eye (7.1%), focal retinochoroiditis in one eye (7.1%), branch retinal vein occlusion (BRVO) due to vasculitis in one eye (7.1%), disc edema with peripapillary serous retinal detachment in one eye (7.1%), and iridocyclitis in one eye (7.1%). Most of the patients (70%) did not experience systemic symptoms preceding the intraocular inflammation. Antimicrobial treatment was efficient in all cases with the exception of the case with neuroretinitis complicated by anterior ischemic optic neuropathy and tubulointerstitial nephritis.

CONCLUSION

Intraocular involvement caused not only by B. henselae but also by B. quintana is being diagnosed with increasing frequency. A high index of suspicion is needed because the spectrum of Bartonella intraocular inflammation is very large. In our study the most common clinical entity was intermediate uveitis.

Culture-negative infectious endocarditis caused by Bartonella spp.: 2 case reports and a review of the literature

Bartonella spp. are rare pathogens in humans and were recently recognized as important causative agents of culture-negative endocarditis. Here, we describe the 1st 2 documented cases of culture-negative endocarditis due to Bartonella henselae and Bartonella quintana encountered in a single hospital in Germany. Infection of the heart valve tissue was detected by broad-range polymerase chain reaction (PCR) and further confirmed by serologic testing. In particular, acute B. henselae infection with an impressive bacterial colonization of the infected cardiac valve was illustrated by transmission electron microscopy. B. henselae was further characterized by PCR assays targeting genotype-specific regions. Disease progression was initially monitored over the entire infection episode through inflammatory markers. In addition, a short overview of published detailed cases of Bartonella endocarditis in Europe within the last 7 years is given.

Oculo-renal disorders in infectious diseases

BACKGROUND

The aim of this article is to review the potential ocular and renal disorders in infectious diseases to which humans are susceptible and to determine prevalence of these diseases.

METHODS

Published cases of oculo-renal disorders associated with various infectious diseases were collected from the international literature by searching the MEDLINE database (PUBMED 1970-2004) for original reports and review articles published in English. Citations from papers retrieved were screened and retrieved papers were evaluated.

RESULTS

Based on the screened data, we propose a practical, structure-oriented checklist of such lesions divided into bacterial, viral, parasital, and fugal infections.

CONCLUSION

The oculorenal manifestations of infectious diseases may be flagrant or subtle. Awareness of the signs and symptoms of infections allows early recognition and prompt, appropriate management. The clinical presentation and relative frequency of those manifestations are reviewed.

Necrotizing glomerulonephritis caused by Bartonella henselae endocarditis

Glomerulonephritis secondary to endocarditis is uncommon and usually associated with valvular infection by blood culture-positive bacteria. We report 3 cases of necrotizing glomerulonephritis associated with culture-negative endocarditis caused by Bartonella henselae. Two of the patients presented with renal abnormalities and were investigated for endocarditis after results of renal biopsy. All 3 patients had an immune complex-mediated necrotizing and crescentic glomerulonephritis with mesangial and capillary wall deposition of immunoglobulin M (IgM), IgG, and C3. Electron microscopy showed immune-type electron-dense deposits in the mesangium and segmental subendothelial (2 cases) or subepithelial (1 case) deposits. Patients were treated with antibiotics, including azithromycin or doxycycline and ceftriaxone or tobramycin. In addition, 2 patients were administered steroids and 2 patients underwent valve replacement surgery. The 2 patients who underwent cardiac surgery were discharged from the hospital with stable renal function. The third patient died 4 months after hospital admission of renal failure. In conclusion, glomerulonephritis caused by B henselae endocarditis is an immune complex-mediated disease characterized by segmental necrotizing and crescentic glomerular lesions that can respond to aggressive medical and surgical therapy.

Clinical impact of persistent Bartonella bacteremia in humans and animals

Bartonella spp. are emerging vector-borne pathogens that cause persistent, often asymptomatic bacteremia in their natural hosts. As our knowledge progresses, it appears that chronic infection may actually predispose the host to mild, insidious nonspecific manifestations or induce, in selected instances, severe diseases. Persistent asymptomatic bacteremia is most common in animals that serve as the main reservoir for the specific Bartonella. In humans, these organisms are B. bacilliformis and B. quintana. Other Bartonella species, for which humans are not the natural reservoir, tend to cause persistent bacteremia only in immunodeficient individuals. In some of these individuals, endothelial cell proliferation may create lesions such as bacillary angiomatosis or bacillary peliosis. In cats, bacteremia of variable level and continuity may last for years. Some strains of B. henselae may induce clinical manifestations, including fever, mild neurological signs, reproductive disorders, whereas others do not induce clinically obvious disease. Reproductive disorders have also been reported in mice experimentally infected with B. birtlesii. Finally, canids constitute the most interesting naturally occurring animal model for the human disease. Like immunocompetent people, healthy dogs only occasionally demonstrate long-term bacteremia when infected with Bartonella spp. However, some dogs develop severe clinical manifestations, such as endocarditis, and the pathologic spectrum associated with Bartonella spp. infection in domestic dogs is rapidly expanding and resembles the infrequently reported clinical entities observed in humans. In coyotes, persistent bacteremia is more common than in domestic dogs. It will be of interest to determine if coyotes develop clinical or pathological indications of infection.