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Lane J, Read JM, Rahmany Z, Reely K, Hicks CM, Martin DE. Development of Palpable Purpura in a Patient With Infective Endocarditis: A Case Report. Cureus 2024; 16:e63601. [PMID: 39087182 PMCID: PMC11290593 DOI: 10.7759/cureus.63601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 08/02/2024] Open
Abstract
Infective endocarditis (IE) can present with a variety of signs and symptoms, including skin lesions. The few papers describing a relationship between IE and vasculitis are split between IE being able to mimic vasculitis and between IE indeed being associated with a vasculitis involving the skin, kidney, gastrointestinal tract, or peripheral nerves. It is important for clinicians to distinguish between an isolated vasculitis, infective endocarditis, and IE-associated vasculitis because the treatments and outcomes are different. We report a case of a patient with a history of intravenous (IV) drug use who initially presented with chest pain, was started on vancomycin following diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) IE, left against medical advice (AMA), and then returned to the hospital due to development of a purpuric rash. We contend that while he did not have a skin biopsy due to time delay, his symmetrically distributed purpura was consistent with cutaneous vasculitis. His symptoms, including his rash and an acute kidney injury (AKI), improved with antibiotics to treat the endocarditis.
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Affiliation(s)
- Jordan Lane
- Internal Medicine, Unity Health, Searcy, USA
| | - John M Read
- Internal Medicine, Unity Health, Searcy, USA
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2
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Lunsford J, Pant P, Rush PS. Infectious Endocarditis Accompanied by Leukocytoclastic Vasculitis. Cureus 2024; 16:e61021. [PMID: 38916001 PMCID: PMC11194134 DOI: 10.7759/cureus.61021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/24/2024] [Indexed: 06/26/2024] Open
Abstract
Bacterial endocarditis is a rare infection that can present with variable clinical manifestations. Rarely, it can present as cutaneous vasculitis characterized by a purpuric rash mimicking immune-mediated vasculitis. There have been a few case reports of leukocytoclastic vasculitis (LCV) due to infectious endocarditis. It is important to recognize endocarditis as a potential cause of vasculitis because treatment with immunosuppressive agents can have devastating consequences. We report a case of a 53-year-old male with endocarditis who developed a palpable purpura of the bilateral lower extremities. A skin biopsy was performed, and histopathologic and immunofluorescence studies demonstrated LCV.
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Affiliation(s)
- Joshua Lunsford
- Internal Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, USA
| | - Prajwol Pant
- Nephrology, Blue Ridge Nephrology Associates, Christiansburg, USA
- Nephrology, Carilion New River Valley Hospital, Christiansburg, USA
| | - Patrick S Rush
- Dermatology, Virginia Tech Carilion School of Medicine, Roanoke, USA
- Dermatology, Dominion Pathology Associates, Roanoke, USA
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Bhuiya T, Skavla B, Gandhi H, Makaryus JN, Steinberg B. A Diagnosis of Endocarditis in a Patient With Suspected Vasculitis. CASE (PHILADELPHIA, PA.) 2023; 7:346-348. [PMID: 37791124 PMCID: PMC10542772 DOI: 10.1016/j.case.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
•IE is rarely associated with multisystem vasculitis. •A high index of suspicion is required to ensure proper treatment of IE. •Mistaking IE for vasculitis and treating with immunosuppressives can be fatal.
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Affiliation(s)
- Tanzim Bhuiya
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, North Shore University Hospital, Manhasset, New York
| | - Brandon Skavla
- Department of Cardiology, Northwell Health, North Shore University Hospital, Manhasset, New York
| | - Himali Gandhi
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, North Shore University Hospital, Manhasset, New York
- Department of Cardiology, Northwell Health, North Shore University Hospital, Manhasset, New York
| | - John N. Makaryus
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, North Shore University Hospital, Manhasset, New York
- Department of Cardiology, Northwell Health, North Shore University Hospital, Manhasset, New York
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Bart Steinberg
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, North Shore University Hospital, Manhasset, New York
- Department of Cardiology, Northwell Health, North Shore University Hospital, Manhasset, New York
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Van Gool IC, Kers J, Bakker JA, Rotmans JI, Teng YKO, Bauer MP. Antineutrophil cytoplasmic antibodies in infective endocarditis: a case report and systematic review of the literature. Clin Rheumatol 2022; 41:2949-2960. [PMID: 35732985 PMCID: PMC9485185 DOI: 10.1007/s10067-022-06240-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 11/03/2022]
Abstract
Infective endocarditis (IE) may be misdiagnosed as ANCA-associated vasculitis (AAV), especially when antineutrophil cytoplasmic antibodies (ANCA) are detected. Distinguishing IE from AAV is crucial to guide therapy. However, little is known about ANCA positivity in IE patients. We present a case report and systematic review of the literature on patients with ANCA-positive IE, aiming to provide a comprehensive overview of this entity and to aid clinicians in their decisions when encountering a similar case. A systematic review of papers on original cases of ANCA-positive IE without a previous diagnosis of AAV was conducted on PubMed in accordance with PRISMA-IPD guidelines. A predefined set of clinical, laboratory, and kidney biopsy findings was extracted for each patient and presented as a narrative and quantitative synthesis. A total of 74 reports describing 181 patients with ANCA-positive IE were included (a total of 182 cases including our own case). ANCA positivity was found in 18-43% of patients with IE. Patients usually presented with subacute IE (73%) and had positive cytoplasmic ANCA-staining or anti-proteinase-3 antibodies (79%). Kidney function was impaired in 72%; kidney biopsy findings were suggestive of immune complexes in 59%, while showing pauci-immune glomerulonephritis in 37%. All were treated with antibiotics; 39% of patients also received immunosuppressants. During follow-up, 69% of patients became ANCA-negative and no diagnosis of systemic vasculitis was reported. This study reviewed the largest series of patients with ANCA-positive IE thus far and shows the overlap in clinical manifestations between IE and AAV. We therefore emphasize that clinicians should be alert to the possibility of an underlying infection when treating a patient with suspected AAV, even when reassured by ANCA positivity. Key Points • This systematic review describes - to our knowledge - the largest series of patients with ANCA-positive infective endocarditis (IE) thus far (N=182), and shows a high degree of overlap in clinical manifestations between IE and ANCA-associated vasculitis (AAV). • ANCA positivity was found in 18-43% of patients with infective endocarditis. Of patients with ANCA-positive IE, the majority (79%) showed cytoplasmic ANCA-staining or anti-PR3-antibodies. We emphasize that clinicians should be alert to the possibility of an underlying infection when treating a patient with suspected AAV, even when reassured by ANCA positivity. • In patients with IE and ANCA-associated symptoms such as acute kidney injury, an important clinical challenge is the initiation of immunosuppressive therapy. All patients with data in this series received antibiotics; 39% also received immunosuppressive therapy. In many of these patients, ANCA-associated symptoms resolved or stabilized after infection was treated. ANCA titers became negative in 69% , and a diagnosis of AAV was made in none of the cases. We therefore recommend that (empiric) antibiotic treatment remains the therapeutic cornerstone for ANCA-positive IE patients, while a watchful wait-and-see approach with respect to immunosuppression is advised.
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Affiliation(s)
- Inge C Van Gool
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| | - Jesper Kers
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pathology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Van 't Hoff Institute for Molecular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap A Bakker
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Laboratory for Genetic Metabolic Diseases, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Y K Onno Teng
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn P Bauer
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Josephson L, Cornea V, Stoner BJ, El-Dalati S. Cryoglobulinemic vasculitis in two patients with infective endocarditis: a case series. Ther Adv Infect Dis 2022; 9:20499361221113464. [PMID: 35937927 PMCID: PMC9354131 DOI: 10.1177/20499361221113464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022] Open
Abstract
Cryoglobulins are circulating immune complexes that precipitate at cool
temperatures and can induce a small-vessel vasculitis. While patients with
endocarditis are well known to have circulating cryoglobulins, cryoglobulinemic
vasculitis is a rare complication of infective endocarditis with infrequent
publication of reported cases. We present two cases of methicillin-resistant
Staphylococcus aureus tricuspid valve infective
endocarditis in patients with substance use disorder complicated by
cryoglobulinemic cutaneous vasculitis confirmed by skin biopsy, including one
patient who developed renal and colonic manifestations of vasculitis. Both
patients had symptomatic improvement in their vasculitis with appropriate
antimicrobial therapy, including one patient who received a short course of
prednisone and another with chronic active hepatitis C that remained untreated.
Providers should have a high-index of suspicion for infective endocarditis in
patients presenting with new onset cryoglobulinemic vasculitis, particularly if
the patients have underlying risk factors for endocarditis.
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Affiliation(s)
- Laura Josephson
- Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Virgilius Cornea
- Department of Pathology and Laboratory Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Bobbi Jo Stoner
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Sami El-Dalati
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky Medical Center, 740 S. Limestone Street Lexington, KY 40536, USA
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Lokineni S, Mohamed A, Gandhi RG, Barrett M. Leukocytoclastic Vasculitis as a Rare Manifestation of Staphylococcal Osteomyelitis. Cureus 2021; 13:e15685. [PMID: 34277274 PMCID: PMC8281794 DOI: 10.7759/cureus.15685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 11/26/2022] Open
Abstract
Leukocytoclastic vasculitis (LCV), also known as small-vessel cutaneous vasculitis, is rarely seen in the setting of staphylococcal infection without bacteremia. Here, we present a case of LCV in a 61-year-old male with chronic staphylococcal osteomyelitis without any evidence of bacteremia. The rash resolved with the treatment of osteomyelitis. As seen in this case, local infection should be considered in the differential diagnosis of LCV even when there is no evidence of bacteremia.
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Affiliation(s)
| | - Amr Mohamed
- Internal Medicine, Rochester Regional Health, Rochester, USA
| | | | - Mary Barrett
- Dermatopathology, Rochester Regional Health, Rochester, USA
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