Nephritic Syndrome Secondary to Granulicatella adiacens Bacteremia

Introduction: Granulicatella adiacens, a gram-positive cocci, is one of the most common bacteria in the oral cavity normal flora. However, it has been increasingly recognized as a cause of significant infections throughout the body and now is thought to be the cause of many cases of culture negative endocarditis. In this case, we report the first known case of G. adiacenscausing infection-related glomerulonephritis (IRGN). Case Description: A 55 year old male with COPD, NASH, and HTN presented with 1 week of progressive shortness of breath, oliguria and dark brown urine, and was found with anuric AKI. On exam he had lower extremity purpura and pitting edema to the hip. Labs revealed creatinine of 6.3mg/dl and albumin of 2.3g/l. Further workup showed a UACR of 832 mg/L, >182 RBCs/hpf, low C3 and normal C4. Blood cultures grew G. adiacens and he was started on vancomycin. Due to pulmonary edema requiring BiPAP limiting the ability to get a kidney biopsy, dermatology performed a punch biopsy which showed leukocytoclastic vasculitis with IgG, IgA, IgM, and C3 staining. Repeat blood cultures confirmed G. adiacens and TEE did not show any vegetations. Serologic workup returned positive c-ANCA 1:20 with PR3 antibodies of 6.1AAU/ml making it difficult to distinguish between an IRGN or ANCA vasculitis which would have drastically different therapies. His renal and respiratory status and he was started on hemodialysis. Eventually, his renal biopsy revealed IgA-dominant infection-related glomerulonephritis (IgA-IRGN). He was successfully treated with 6 weeks of vancomycin. 2 months later he was able to come off dialysis with a GFR of 25. Discussion: IgA-IRGN is a distinct form of IRGN, with predominant IgA complex deposition, typically secondary to deep seated staphylococcus or enterococcus infections. This is the first case reported of the increasingly pathologic G. adiacens causing IgA-IRGN. This case was further complicated by ANCA positivity which can be seen in about 15% of IRGN, though this is the first case demonstrating a positive ANCA with G adiacens. Distinguishing these 2 diseases is of utmost clinical importance as the treatments are diametrically opposed.