Streptococcal viridans subacute bacterial endocarditis associated with antineutrophil cytoplasmic autoantibodies (ANCA)

doi:10.1067/mhl.2003.2

Heart & Lung

Volume 32, Issue 2, March–April 2003, Pages 140-143

https://doi.org/10.1067/mhl.2003.2 Get rights and content

Abstract

We report an illustrative case of a 60-year-old man with Streptococcus viridans subacute bacterial endocarditis (SBE) and positive antineutrophil cytoplasmic autoantibodies (c-ANCA). C-ANCA positivity has been associated with a variety of rheumatic and infectious disease areas, but has been rarely associated with SBE. The patient had mitral valve prolapse with mitral regurgitation, and S viridans SBE developed after a dental procedure. Laboratory abnormalities included anemia, elevated erythrocyte sedimentation rate, positive rheumatoid factor, positive anticardiolipin antibody, positive lupus anticoagulant, and highly elevated c-ANCA level. We believe this is only the ninth reported case of S viridans SBE with a positive c-ANCA, and the third with mitral valve prolapse and vegetations. (Heart Lung® 2003;32:140-3.)

Section snippets

Illustrative case

A 60-year-old man was admitted to the hospital with a 5-month history of “weight loss and not feeling well.” Symptoms began with cough occasionally productive of blood-tinged sputum, nausea, and vomiting. This progressed to muscle aches, decreased appetite, and fatigue. The patient lost a total of 55 lbs during this 5-month period. Two weeks before arriving at the hospital, the patient was empirically treated with 500 mg of oral levofloxacin every 24 hours for one week, but the treatments was

Hospital course

The patient had an extensive workup that included pulmonary function testing as a screening test for possible pulmonary disease, which were normal. In an attempt to rule out a malignant focus, computed tomography of the chest, abdomen, and pelvis was obtained, which were unremarkable except for splenomegaly.

Biopsy of the lower extremity rash revealed a leukocytoclastic (allergic) vasculitis attributed to an allergic reaction to levofloxacin. The patient had a renal biopsy with global retraction

Discussion

S viridans SBE commonly occurs in the setting of valvular disease, as in our patient, and it is characterized by a slow, indolent course with low-grade fever (<102°F), night sweats, weight loss, and vague systemic complaints.1, 2

SBE stimulates both humoral and cellular immunity, manifested by hypergammaglobulinemia and splenomegaly. Increased IgM RF develop in approximately 50% of patients with SBE of more than 6 weeks duration. RF titers correlate with duration or degree of

References (24)

CGM Kallenberg et al.
Antineutrophil cytoplasmic autoantibodies: current diagnostic and pathophysiological potential
Kidney Int
(1994)
WH Schmitt et al.
ANCA and infection
Lancet
(1991)
J Koderisch et al.
“False-positive” anti-neutrophil cytoplasmic antibodies in HIV infection
Lancet
(1990)
D Kemmett et al.
Antibodies to neutrophil cytoplasmic antigens: serologic marker for Sweet's syndrome
J Am Acad Dermatol
(1991)
P Von Den Driesch
Sweet's syndrome [acute febrile neutrophilic dermatosis]
J Am Acad Dermatol
(1994)
JC Jennette et al.
Antineutrophil cytoplasmic autoantibodies and associated diseases: a review
Am J Kid Dis
(1990)
IK Choi et al.
Subacute bacterial endocarditis with positive cytoplasmic antineutrophil cytoplasmic antibodies and anti-proteinase 3 antibodies
Arthritis Rheum
(2000)
T Haseyama et al.
Proteinase-3-antineutrophil cytoplasmic antibody [PR3-ANCA] positive crescentic glomerulonephritis in a patient with Down's syndrome and infectious endocarditis
Nephrol Dial Transplant
(1998)

A Soto et al.

Endocarditis associated with ANCA

Clin Exp Rheumatol

(1994)

I Wagner et al.

Is vasculitis in subacute bacterial endocarditis associated with ANCA?

Lancet

(1991)

Cited by (28)

Antineutrophil cytoplasmic antibodies associated with infective endocarditis: Literature review
2017, Revue de Medecine Interne
Les endocardites infectieuses associées aux anticorps anticytoplasme des polynucléaires neutrophiles (ANCA) représentent une entité anatomoclinique rare. Elles peuvent mimer d’authentiques vascularites ANCA-positives. Ainsi, la présence d’ANCA peut égarer le clinicien et faire poser à tort le diagnostic de localisation valvulaire cardiaque liée à une vascularite systémique chez un patient présentant une endocardite infectieuse associée aux ANCA ; la prise en charge de ces deux pathologies étant fondamentalement différente, cette confusion peut avoir des conséquences dramatiques pour les patients. Dans cette mise au point, nous passerons en revue les différents aspects cliniques, évolutifs et pronostiques des endocardites infectieuses associées aux ANCA et proposerons un algorithme diagnostique.
Antineutrophil cytoplasmic antibodies (ANCA) associated with infective endocarditis are a rare disorder. The condition can mimic primary systemic vasculitis (i.e. granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis). Thus, a wrong diagnosis of valvular involvement related to primary systemic vasculitis can be made in patients exhibiting ANCA associated with infective endocarditis. Because treatment of both conditions is different, this wrong diagnosis will lead to dramatic consequences in these latter patients. This review reports the state of knowledge and proposes an algorithm to follow when confronted to a possible case of ANCA associated with infective endocarditis.
Shunt Nephritis and Pyogenic Spondylitis With a Positive PR3-ANCA Associated With Chronically Infected Ventriculoatrial Shunt
2017, Anuario de Psicologia
Citation Excerpt :
ANCA formation has been reported in the course of various chronic viral (e.g., HIV, Hepatitis B, Hepatitis C), bacterial (e.g., Streptococcus, Staphylococcus, Enterococcus), fungal (e.g., Aspergillus), protozoal (e.g., Streptococcus, Staphylococcus, Enterococcus), and multicellular parasitic infection (e.g., Echinococcus).13 For example, PR3-ANCA in infectious endocarditis is a typical disease.14,15 In shunt nephritis, PR3-ANCA could also become positive.
Antineutrophil cytoplasmic antibodies in pneumology
2011, Immuno-Analyse et Biologie Specialisee
Antineutrophil cytoplasmic antibodies (ANCA) are classical serological markers of small-vessels vasculitis. However, they have been described in many others pathological situations. The aim of our study was to determinate clinical usefulness of ANCA in pulmonary institute. Forty-three out of 1070 (4%) patients have positives ANCA by indirect immunofluorescence. Only 24% of patients have small vessels vasculitis. ANCA are targeting the bactericidal-permeability-increasing-protein (BPI) in mainly cases. In our study, ANCA are mainly linked to chronic airway infections such as cystic fibrosis and bronchectases in which they may have long exposure to Gram-negative bacteria. Indirect immunofluorescence (IIF) remains the most widely used technique for ANCA detection. All samples positives by immunofluorescence should have specificity confirmed by Elisa.
Les anticorps anticytoplasme des polynucléaires neutrophiles (ANCA) sont décrits classiquement comme étant des marqueurs sérologiques des vascularites touchant les petits vaisseaux. Cependant la liste des pathologies associées aux ANCA ne cesse de s’allonger. L’objectif de notre étude était de préciser la prévalence et la signification clinique des ANCA en milieu pneumologique. Quarante-trois (4 %) des 1070 patients avaient des ANCA positifs par immunofluorescence indirecte (IFI). La bactericidal-permeability-increasing-protein (BPI) est la spécificité antigénique la plus détectée. Notre étude montre qu’en milieu pneumologique les ANCA sont surtout associés aux pathologies inflammatoires chroniques pulmonaires : dilatation des bronches, fibrose pulmonaire où il peut y avoir des phénomènes de suppuration chronique par les bacilles Gram négatifs (BGN). L’IFI est la méthode de référence pour la détection des ANCA. En cas de positivité, elle doit être couplée à l’Elisa pour la détermination de la spécificité antigénique.
Fatal Streptococcus viridans (S. oralis) aortic prosthetic valve endocarditis (PVE) with paravalvular abscesses related to steroids
2009, Heart and Lung: Journal of Acute and Critical Care
Citation Excerpt :
Furthermore, clinicians may be misled by the presence of laboratory tests, which are usually associated with rheumatic disorders but have also been associated with SBE, that is, antineutrophilic cytoplasmic antibodies. Clinicians must also be aware that antineutrophilic cytoplasmic antibody positivity may occur with rheumatic diseases but also may be a nonspecific laboratory finding of SBE.19,20 Clinicians must be vigilant not to ascribe all patients with low-grade fevers, malaise, and muscular skeletal symptoms to a rheumatic process, particularly patients with prosthetic heart valves.
Antineutrophil cytoplasmic antibodies in infective endocarditis: a case report and systematic review of the literature
2022, Clinical Rheumatology
Infective endocarditis mimicking ANCA-associated vasculitis: does it require immunosuppressive therapy? A case report and literature review
2020, Medicine (United States)

View all citing articles on Scopus

^*: Reprint requests: Burke A. Cunha, MD, Chief, Infectious Disease Division, Winthrop-University Hospital, Mineola, NY 11501.

^**: 0147-9563/2003/$30.00 + 0

View full text

Case Studies in Infectious DiseaseStreptococcal viridans subacute bacterial endocarditis associated with antineutrophil cytoplasmic autoantibodies (ANCA)*,**

Abstract

Section snippets

Illustrative case

Hospital course

Discussion

Kidney Int

Lancet

Lancet

J Am Acad Dermatol

J Am Acad Dermatol

Am J Kid Dis

Subacute bacterial endocarditis with positive cytoplasmic antineutrophil cytoplasmic antibodies and anti-proteinase 3 antibodies

Arthritis Rheum

Proteinase-3-antineutrophil cytoplasmic antibody [PR3-ANCA] positive crescentic glomerulonephritis in a patient with Down's syndrome and infectious endocarditis

Nephrol Dial Transplant

Endocarditis associated with ANCA

Clin Exp Rheumatol

Is vasculitis in subacute bacterial endocarditis associated with ANCA?

Lancet

Case Studies in Infectious Disease
Streptococcal viridans subacute bacterial endocarditis associated with antineutrophil cytoplasmic autoantibodies (ANCA)*,**