Dark masses of bacteria (arrows) embedded in fibrin. Valve leaflet (below) diffusely ... Subacute bacterial endocarditis fits with the clinical valvular replacement ...
Nephrol Dial Transplant ( 1997) 12: 839–841
Nephrology Dialysis Transplantation
Teaching Point
(Section Editor: K. Ku¨hn) ANCA-positive rapidly progressive glomerulonephritis: there may be more to the diagnosis than you think! Th. Messiaen, Ch. Lefebvre, F. Zech, J. P. Cosyns and M. Jadoul Departments of Nephrology, General Internal Medicine and Pathology, Cliniques Universitaires Saint-Luc, University of Louvain Medical School, B-1200 Brussels, Belgium
Case report A previously healthy 56-year-old woman was referred for evaluation of fatigue, skin lesions and renal failure. She had noticed for several months progressive asthenia, nocturnal sweats, intermittent fever ( 38°C ), anorexia and a 3 kg weight loss. Two weeks before admission, red spots appeared on the legs. At that time, erythrocyte sedimentation rate reached 60 mm/h, while serum creatinine had risen to 154 mmol/l from 88 mmol/l 1 month earlier. On admission, cardiopulmonary auscultation was normal. Blood pressure was 120/80 mmHg. Noticeable findings were palpable purpura on the legs and mild spleen enlargement. Serum C-reactive protein (CRP); ( 5 mg/l ) and plasma fibrinogen (212 mg/dl ) were normal. Serum creatinine was elevated (181 mmol/l ). Additional tests included: haemoglobin 8.2 g/dl with microcytosis (71.6 m3 ), iron 17 mg/dl, TIBC 224 mg/dl, ferritin 269 mg/ml, white cell count 3.69×109/l (neutrophils 56%), platelets 150×109/l, total protein serum level 90 g/l (albumin 32 g/l, gamma-globulins 42 g/l ( IgM 0.41 g/l, IgG 3.59 g/l, without evidence of monoclonal component)). Urinalysis disclosed 80–90 red blood cells/hpf with red cell casts; proteinuria was 1.8 g/24 h. Several autoantibodies were detected: antinuclear antibodies (ANA) at a titre of 1/320 (nucleolar and speckled patterns), anticardiolipin antibodies 61 U.GPL (normal < 10 ), perinuclear ANCA at a titre of 1/2560 without reactivity, by ELISA, for myeloperoxidase, elastase, cathepsin or lactoferrin extracts. C3 serum level was 0.6 g/l (normal 0.7–1.3). A mixed type III cryoglobulin ( IgM–IgG) was detected ( 0.7 mg/ml, normal
