Infective Endocarditis-Associated Glomerulonephritis Caused by Streptococcus cristatus: A Case Report

Infective endocarditis (IE) can trigger systemic embolic and immune-mediated complications, including infection-related glomerulonephritis. When the infectious focus is IE, the condition is termed IE-associated glomerulonephritis (IEAGN). A major diagnostic pitfall is that IEAGN may present with purpura, nephritic urinary abnormalities, systemic inflammation, and antineutrophil cytoplasmic antibody (ANCA) positivity, closely mimicking primary small-vessel vasculitis and risking inappropriate immunosuppression if infection is not promptly excluded.

A 52-year-old woman with mitral valve prolapse presented with fever, malaise, and palpable purpura. Laboratory testing demonstrated systemic inflammation, renal dysfunction with proteinuria and hematuria, and marked proteinase 3-antineutrophil cytoplasmic antibody (PR3-ANCA) positivity (121 U/mL). Blood cultures obtained for persistent fever yielded Streptococcus cristatus. Transesophageal echocardiography demonstrated large vegetations on the mitral valve (19 mm on the anterior leaflet and 11 mm on the posterior leaflet), with severe mitral regurgitation. Neuroimaging identified a right occipital hemorrhage and small peripheral intracranial aneurysms. Kidney biopsy demonstrated necrotizing and crescentic glomerulonephritis with a granular immune-complex staining pattern on immunofluorescence (C3/C1q/IgG/IgM/IgA) and mesangial electron-dense deposits on electron microscopy, supporting an immune-complex-mediated glomerulonephritis in the setting of IE. She was treated with ceftriaxone and underwent early mitral valve replacement for large vegetations, severe mitral regurgitation, and disseminated lesions. Renal function improved without corticosteroids or other immunosuppressants. During more than 8 weeks of antibiotic therapy, her serum PR3-ANCA level decreased from 121 to 63.8 U/mL by hospital day 73.

S. cristatus IE can present with vasculitis-like features and a markedly elevated serum PR3-ANCA concentration, closely mimicking ANCA-associated vasculitis. This case emphasizes that ANCA positivity does not rule out infection and highlights the importance of early integration of blood cultures, echocardiography, and renal pathology to support clinicopathological diagnosis and avoid premature immunosuppression.