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      Antineutrophil cytoplasmic antibodies (ANCA)-positive patient with infective endocarditis and chronic hepatitis B virus: a case report and review of the literature

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          Abstract

          Background

          Antineutrophil cytoplasmic antibodies comprise a family of autoantibodies that are often used as biomarkers for certain forms of small-vessel vasculitis; however, chronic infections tend to induce the production of antineutrophil cytoplasmic antibodies. Infective endocarditis and hepatitis B virus infection have been reported to exhibit antineutrophil cytoplasmic antibody positivity and to mimic antineutrophil cytoplasmic antibody–associated vasculitis, which may lead to misdiagnosis and inappropriate treatment.

          Case presentation

          We report a case of a 46-year-old Han Chinese man with untreated chronic hepatitis B virus infection who featured proteinase-3 antineutrophil cytoplasmic antibody positivity while hospitalized with infective endocarditis. Cardiac ultrasound echocardiography disclosed mitral and aortic regurgitation with vegetation. On the 15th hospital day, the patient underwent mitral and aortic valve replacement and was then treated with antibiotics for more than 1 month. On the 57th hospital day, the patient was discharged. His urinary abnormalities and renal function were gradually recovering. Four months after being discharged, his proteinase-3 antineutrophil cytoplasmic antibody levels had returned to the normal range.

          Conclusions

          The findings in this study update and expand current understanding of antineutrophil cytoplasmic antibody positivity in patients with both infective endocarditis and hepatitis B virus. Treatment (including surgery, antibiotics, corticosteroids and/or cyclophosphamide, antiviral agents, and even plasma exchange) is challenging when several diseases are combined. Renal biopsy is suggested if the patient’s condition allows. Antineutrophil cytoplasmic antibody testing should be repeated after therapy, because some cases might require more aggressive treatment.

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          Infective endocarditis in adults.

          E Mylonakis, S B Calderwood (2001)
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            Changing profile of infective endocarditis: results of a 1-year survey in France.

            François Delahaye, Catherine Leport, … (2002)
            Since the first modern clinical description of infective endocarditis (IE) at the end of the 19th century, the profile of the disease has evolved continuously, as highlighted in epidemiological studies including a French survey performed in 1991. To update information gained from the 1991 study on the epidemiology of IE in France. Population-based survey conducted from January through December 1999 in all hospitals in 6 French regions representing 26% of the population (16 million inhabitants). Three hundred ninety adult inpatients diagnosed with IE according to Duke criteria. Incidence of IE; proportion of patients with underlying heart disease; clinical characteristics; causative microorganisms; surgical and mortality outcomes. The annual age- and sex-standardized incidence was 31 (95% confidence interval [CI], 28-35) cases per million, not including the region of New Caledonia, which had 161 (95% CI, 117-216) cases per million. There was no previously known heart disease in 47% of the cases. The proportion of prosthetic-valve IE was 16%. Causative microorganisms were: streptococci, 48% (group D streptococci, 25%; oral streptococci, 17%, pyogenic streptococci, 6%); enterococci, 8%; Abiotrophia species, 2%; staphylococci, 29%; and other or multiple pathogens, 8%. Blood cultures were negative in 9% and no microorganism was identified in 5% of the cases. Early valve surgery was performed in 49% of the patients. In-hospital mortality was 16%. Compared with 1991, this study showed a decreased incidence of IE in patients with previously known underlying heart disease (20.6 cases per million vs 15.1 cases per million; P<.001); a smaller incidence of oral streptococcal IE (7.8 cases per million vs 5.1 cases per million; P<.001), compensated by a larger proportion of IE due to group D streptococci (5.3 cases per million vs 6.2 cases per million; P =.67) and staphylococci (4.9 cases per million vs 5.7 cases per million; P =.97); an increased rate of early valve surgery (31.2% vs 49.7%; P<.001); and a decreased in-hospital mortality rate (21.6% vs 16.6%; P =.08). Although the incidence of IE has not changed, important changes in disease characteristics, treatment, and outcomes were noted.
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              Infective Endocarditis in the U.S., 1998–2009: A Nationwide Study

              David H Bor, Steffie Woolhandler, Rachel A. Nardin … (2013)
              Background Previous studies based on local case series estimated the annual incidence of endocarditis in the U.S. at about 4 per 100,000 population. Small-scale studies elsewhere have reported similar incidence rates. However, no nationally-representative population-based studies have verified these estimates. Methods and Findings Using the 1998–2009 Nationwide Inpatient Sample, which provides diagnoses from about 8 million U.S. hospitalizations annually, we examined endocarditis hospitalizations, bacteriology, co-morbidities, outcomes and costs. Hospital admissions for endocarditis rose from 25,511 in 1998 to 38, 976 in 2009 (12.7 per 100,000 population in 2009). The age-adjusted endocarditis admission rate increased 2.4% annually. The proportion of patients with intra-cardiac devices rose from 13.3% to 18.9%, while the share with drug use and/or HIV fell. Mortality remained stable at about 14.5%, as did cardiac valve replacement (9.6%). Other serious complications increased; 13.3% of patients in 2009 suffered a stroke or CNS infection, and 5.5% suffered myocardial infarction. Amongst cases with identified pathogens, Staphylococcus aureus was the most common, increasing from 37.6% in 1998 to 49.3% in 2009, 53.3% of which were MRSA. Streptococci were mentioned in 24.7% of cases, gram-negatives in 5.6% and Candida species in 1.0%. We detected no inflection in hospitalization rates after changes in prophylaxis recommendations in 2007. Mean age rose from 58.6 to 60.8 years; elderly patients suffered higher rates of myocardial infarction and death, but slightly lower rates of Staphylococcus aureus infections and neurologic complications. Our study relied on clinically diagnosed cases of endocarditis that may not meet strict criteria. Moreover, since some patients are discharged and readmitted during a single episode of endocarditis, our hospitalization figures probably slightly overstate the true incidence of this illness. Conclusions Endocarditis is more common in the U.S. than previously believed, and is steadily increasing. Preventive efforts should focus on device-associated and health-care-associated infections.
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                Author and article information

                Contributors
                Qian Zhang: bearaly@126.com
                Baoxian Shi: chip0731@163.com
                Hongbing Zeng: zeng-hong-bing@163.com
                Journal
                Journal ID (nlm-ta): J Med Case Rep
                Journal ID (iso-abbrev): J Med Case Rep
                Title: Journal of Medical Case Reports
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1752-1947
                Publication date (Electronic): 6 July 2020
                Publication date PMC-release: 6 July 2020
                Publication date Collection: 2020
                Volume: 14
                Electronic Location Identifier: 90
                Affiliations
                [1 ]GRID grid.33199.31, ISNI 0000 0004 0368 7223, Division of Nephrology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, , Huazhong University of Science and Technology, ; Wuhan, Hubei People’s Republic of China
                [2 ]GRID grid.412969.1, ISNI 0000 0004 1798 1968, Department of Chemistry and Environmental Engineering, , Wuhan Polytechnic University, ; Wuhan, Hubei People’s Republic of China
                Article
                Publisher ID: 2373
                DOI: 10.1186/s13256-020-02373-1
                PMC ID: 7336675
                PubMed ID: 32624005
                SO-VID: fe273cb0-414a-42d0-a936-61c2c0ecd794
                Copyright © © The Author(s) 2020
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 3 August 2019
                Date accepted : 17 March 2020
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2020

                ScienceOpen disciplines: Medicine
                Keywords: case report,antineutrophil cytoplasmic antibodies,infective endocarditis,hepatitis b virus infection
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: case report, antineutrophil cytoplasmic antibodies, infective endocarditis, hepatitis b virus infection

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