A Lurking Raging Infection in an Apparent Case of ANCA Vasculitis
Orthopedics and Rheumatology Open Access Journal
The association between Infective Endocarditis (IE) and positive testing for Anti-Neutrophil Cytoplasmic Antibody (ANCA) can raise diagnostic as well as treatment dilemmas. This is a case of a 39 year old Caucasian female without history of intravenous drug abuse who presented with worsening bilateral leg painful and purpuric rash for 1 week. Laboratory data was significant for normal CBC, white count and complement levels whereas creatinine was 4.49 mg/dl with a normal baseline, hepatitis C
... ine, hepatitis C positive, C-ANCA titer 1:40 (anti-proteinase 3 positive) and urinalysis with 1+ blood and protein. Patient was presumptively treated as ANCA vasculitis with high dose steroids as a kidney biopsy could not be obtained due to thin cortex on renal ultrasound. Three days later she developed shortness of breath and chest x-ray revealed nodular opacities triggering CT chest that showed possible septic emboli together with a new 3/6 systolic murmur at left parasternal area. Blood cultures were positive for MRSA and transthoracic echocardiogram revealed moderate to severe tricuspid regurgitation with possible vegetation later confirmed on transesophageal echocardiogram. Steroids were immediately replaced by vancomycin resulting in complete recovery of rash and bacteremia by five weeks. Infective endocarditis is known to produce a wide variety of clinical manifestations. A few cases in which IE presented as ANCA vasculitis have been reported.