亞急性菌性心內膜炎：一個易被忽略的急性腎衰竭及腎絲球腎炎的原因

Subacute Bacterial Endocarditis: An Easily Neglected Cause of Acute Renal Failure and Glomerulonephritis

10.7023/TJFM.200209.0129

張榮哲(Jung-Che Chang)；黃麗卿(Lee-Ching Hwang)；鍾嫈嫈(Jin-Jin Tjung)；吳志仁(Chin-Jen Wu)；吳再成(Tsai-Cheng Wu)

infective endocarditis ； glomerulonephritis ； subacute bacterial endocarditis ； immunosuppressant ； C-ANCA

台灣家庭醫學雜誌

12卷3期（2002 / 09 / 01）

129 - 136

繁體中文

腎絲球腎炎是感染性心內膜炎一個重要的併發症。本報告介紹一名47歲女性病人，第一次住院時表現急性腎衰竭症狀，診斷為急性腎絲球腎炎，而投與免疫抑制劑治療;第二次住院表現為鬱血性心衰竭，才診斷出感性染性心內膜炎合併腎絲球腎炎，經抗生素治療和人工瓣模置換手術而痊癒。本病例值得注意之處有二:一、病人第一次住院時未接受抗生素治療，腎功能卻恢復至正常，可能與使用免疫抑制劑(prednisolone, cyclophosphamide)有關。二、此病人之C-ANCA為陽性反應。C-ANCA陽性通常存在於Wegener’s granulomatosis患者，而亞急細菌性心內膜炎合併腎絲球腎炎和C-ANCA陽性的關連，值得進一步研究。

Glomerulonephritis is an important complication of infective endocarditis. The purpose of this report is to show that a 47 y/o female patient presented with symptoms of acute renal failure in her first admission. The diagnosis was acute glomerulonephritis, and immunosuppressants were given. When she presented with symptoms of congestive heart failure in her second admission, infective endocarditis, complicated with glomerulonephritis was just diagnosed. She was then cured after antibiotics therapy and cardisc prosthetic valve replacement. There are two notable points about this patient. Firstly, the patient’s renal function returned to normal range without antibiotics treatment in the first admission. This might be the effect of immunosuppressants (prednisolone, cyclophosphamide) used. Seeondly, the patient had a positive C-ANCA test. Since the positive C-ANCA test is usually found in patients with Wegener’s granulomatosis, the correlation between subacute bacterial endocarditis complicated with glomerulonephritis and C-ANCA is worthy of further study.

1. Bayer AS,Bolger AF,Taubert KA(1998).Diagnosis and management of infective endocarditis and its complications.Circulation,98,2936-2948.
2. Bayer AS,Theofilopoulos AN(1990).Immunopathogenetic aspects of infective endocarditis.Chest,97,204-212.
3. Daimon S.,Mizuno Y,Fujii S.(1998).Infective endocarditis-induced creacentic glomerulonephritis dramatically improved by plasmapheresis.Am J Kidney Dis,32,309-313.
4. Gao GW,Lin SH,Lin YF(1996).Infective endocarditis complicated with rapidly progressive glomerulonephritis: a case report.Chin Med J,57,439-443.
5. Gutman RA,Striker GE,Gilliland BC,Cutler RE(1972).The immune complex glomerulonephritis of bacterial endocarditis.Medicine (Baltimore),51,1-25.
6. Hogevik H,Olaison L,Andersson R,Lindberg J,Alestig K(1995).Epidemiologic aspects of infective endocarditis in an urban population: a 5-year prospective study.Medicine,74,324-339.
7. Kannan S,Mattoo TK(2001).Diffuse crescentic glomerulonephritis in bacterial endocarditis.Pediatr Nephrol,16,423-428.
8. Karchmer AW,E Braunwald(eds.)(2000).Infective endocarditis.Heart Disease,1723-1750.
9. Le Moing V,Lacassin F,Deahousse M(1999).Use of corticosteroids in glomerulonephritis related to infective endocarditis: three cases and review.Clin Infect Dis,28,1057-1061.
10. Majumdar A,Chowdhary S,Ferreira MA(2000).Renal pathological findings in infective endocarditis.Nephrol Dial Transplant,15,1782-1787.
11. Mansur AJ,Grinberg M,da Liz PL(1992).The complications of infective endocarditis: A reappraisal in the 1980s.Arch Intern Med,152,2428-2432.
12. McKinsey DS,McMurray TL,Flynn JM(1990).Immune complex glomerulonephritis associated with Staphylococcus aureus bacteremia: response to corticosteroid therapy.Rev Infect Dis,12,125-127.
13. Neugarten J,Baldwin DS(1984).Glomerulonephritis in bacterial endocarditis.Am J Med,77,297-304.
14. Orfila C,Lepert JC,Modesto A(1993).Rapidly progressive glomerulonephritis associated with bacterial endocarditis: efficacy of antibiotic therapy alone.Am J Nephrol,13,218-222.
15. Rovzar MA,Logan JL,Ogden DA,Graham AR(1986).Immunosuppressive therapy and plasmapheresis in rapidly progressive glomerulonephritis associated with bacterial endocarditis.Am J Kidney Dis,7,428-433.
16. Soto A,Jorgensen C,Oksman F,Noel LH,Sany J(1994).Endocarditis associated with ANCA.Clin Exp Rheumatol,12,203-204.
17. Subra JF,Michelet C,Laporte J.(1998).The presence of cytoplasmic antineutrophil cytoplasmic antibodies (ANCA) in the course of subacute bacterial endocarditis with glomerular involvement, coincidence or association.Clin Nephrol,49,15-18.
18. Wagner J,Andrassy K,Ritz E(1991).Is vasculitis in subacute bacterial endocarditis associated with ANCA.Lancet,337,799-800.