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Diffuse Proliferative Glomerulonephritis and Acute Renal Failure Associated with Acute Staphylococcal Osteomyelitis

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Diffuse Proliferative Glomerulonephritis and Acute Renal Failure Associated with Acute Staphylococcal Osteomyelitis Diffuse Proliferative Glomerulonephritis and Acute Renal Failure Associated with Acute Staphylococcal Osteomyelitis MATTHEW D. GRIFFIN,* JOHANNES BJORNSSON,t and STEPHEN B. ERICKSON* *Department of Internal Medicine, Division of Nephrology, and tDepartment of Pathology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Abstract. A 72-year-old man developed acute renal failure after peated surgical debridement. Spontaneous recovery of renal coronary bypass surgery that had been complicated by sternal function occurred after eradication of infection and final sur- osteomyelitis caused by the Staphylococcus aureus bacterium. gical wound repair. The relationship between acute bacterial Bacteremia and sepsis were not present. Renal biopsy demon- infections and glomerulonephritis and, in particular, the causal strated a florid, diffuse, proliferative glomerulonephritis with role of staphylococcal antigens in the pathogenesis of such glomerular immune complex deposition. Management in- lesions is discussed. (J Am Soc Nephrol 8: 1633-1639, 1997) cluded hemodialysis, prolonged antibiotic therapy, and re- Coagulase-positive staphylococcus (Staphylococcus aureus) is mg/dl]) and in the immediate postoperative period. Over the the most common causative organism in acute osteomyelitis following days, the patient’s serum creatinine concentration (1). Along with coagulase-negative staphylococcal species, it increased progressively, and hemodialysis was instituted on has also been implicated in the pathogenesis of immune com- day 23 after CABG. There was no past or family history of plex (IC)-mediated diffuse proliferative glomerulonephritis renal disease and no known drug allergies. Prior medical (DPGN) in a variety of infections. These include bacterial history had included degenerative disc disease, stable abdom- endocarditis, ventriculoatrial shunt infections, pneumonia, and inal aortic aneurysm, stable benign prostatic hyperplasia, and visceral abscesses with or without septicemia (2-6). No clearly depression. documented cases of glomerulonephritis with acute renal fail- The patient had been readmitted to his home hospital with ure (ARF) in association with staphylococcal osteomyelitis fever and purulent discharge from his wound 8 days after have previously been reported. We describe an episode of surgery. Blood cultures were negative at this time and on three biopsy-proven DPGN with rapidly progressive ARF occurring other occasions during the illness. Wound packing and empiric after postoperative wound infection and sternal osteomyelitis antibiotic therapy with intravenous vancomycin had failed to caused by S. aureus. Spontaneous recovery occurred after improve his wound infection, and surgical debridement with eradication of the infection through prolonged antibiotic ther- rewiring of the sternum was first carried out 10 ten days after apy and multiple surgical debridements. CABG. Staphylococcus aureus had been cultured from wound tissue and sternal bone marrow at this time, and therapy with Case Report intravenous anti-staphylococcal antibiotic therapy had been Presentation and Management continued. The patient, a 72-year-old white man, was transferred to our At the onset of ARF, urinalysis was reported as showing institution from another medical facility for further manage- microhematuria (5 to 9 cells per high-power field) with gran- ment of postsurgical sternal wound infection and ARF. Thirty- ular casts. Additional pertinent studies during this period in- four days before transfer, he had undergone coronary artery cluded persistently normal platelet count and negative serolo- bypass graft surgery (CABG) for treatment of severe three- gies for hepatitis A, B, and C; antinuclear antibody, anti- vessel disease. Figure 1 summarizes the course of his ARF double-stranded DNA antibody, and perinuclear and both before and after transfer and highlights important thera- cytoplasmic antineutrophil cytoplasmic antibodies. Serum C3 peutic interventions. An increased serum creatinine concentra- and C4 complement levels were documented on day 22 after tion ( 133 pmolIL [1 .5 mg/dl]) had first been noted 18 days CABG at 91 mg/dl (normal range, 86 to 184 mg/dl) and 23 after CABG, having been normal on day 15 (80 jtmolIL [0.9 mg/dl (normal range, 20 to 59 mg/dl), respectively. Renal ultrasound showed both kidneys to be of normal size and appearance without evidence of obstruction. Renal biopsy was carried out on day 26 and high-dose corticosteroid therapy was Received July 31, 1996. Accepted January 17, 1997. Correspondence to Dr. Stephen B. Erickson, Division of Nephrology, Mayo begun on day 28. Building, W l2B, Mayo Clinic and Foundation, 200 First St. SW, Rochester. MN 55905. Renal Biopsy Results 1046-6673/08010- l633$03.00/0 Journal of the American Society of Nephrology Eleven glomeruli, all viable, were available for light micros- Copyright © 1997 by the American Society of Nephrology copy. Endocapillary cellular proliferation was diffuse and gen- 1634 Journal of the American Society of Nephrology 1000 Renal Biopsy Transfer C * * E 9. 700 600 500 c)1. E 400 I- 4? 300 ri 200 100 p 0 - 0 0 0 0 0 c, c ‘, I0 0 4RtiQc T4PY IIemodlysis :prticoserp#{248}Thpy IRfrctlp!! ttd * F’i jgi#{231}qpsure * !ys ?!st !Y?SS S4!Y Figure 1. Graph of serum creatinine values after coronary bypass surgery. demonstrating the course of acute renal failure episode and showing the timing and duration of treatment modalities as well as the definitive surgical procedure. eralized (Figure 2A). Proliferation was accounted for by rues- home with a serum creatinine concentration of 141 .tmolIL angial cells and polymorphonuclear leukocytes. A few ( I .6 mg/dl) and satisfactory wound healing. capillary loops displayed peripheral extension of mesangial cell cytoplasm and nuclei. Six glorneruli were examined on irnrnunofluorescent microscopy, revealing strong granular re- Th4i1!!! activity to inimunoglobulin G (IgG), both within glomerular This case clearly documents an IC-mediated, diffuse prolif- erative gbomerubonephritis occurring as a result of acute osteo- mesangiuni and along capillary walls. C3 complement had a myelitis. The temporal relationship between the staphybococcal similar but somewhat less intense distribution. IgA. 1gM, and infection and ARF in both onset and eventual resolution, along kappa and lambda light chains of identical texture were like- with the unequivocal histopathobogical findings, leave no wise identified in a similar but significantly less intense pat- doubt as to this association. As such it joins only a handful of tern. cases in which acute bone or joint infection has been clearly Electron microscopy (Figure 2B confirmed the presence of linked to a gbonierulonephritis (7-9). More broadly, however, immune deposits along the internal aspect of peripheral gb- it conforms to the well-recognized occurrence of jC-mediated merular basement membranes and in gbomerular mesangium, glomerulonephritis with certain infections in which the patho- associated with cellular proliferation and focal peripheral ex- genie organism is, to some degree, sequestered from rapid teflsion of mesangial cells. clearance by the immune system and in which progression to chronicity may result. These include ventricuboatrial shunt infections (3), bacterial endocarditis (2), visceral abscesses, Outconze empyema, and others (4,6,10). Such infections may be as As shown in Figure 1 , corticosteroid therapy was tapered clinically obvious as a septicenlia or may represent occult and discontinued shortly after transfer, and vancomycin was infection presenting with ARF of unclear cause. They can also continued until close to discharge. Multiple surgical debride- be regarded as distinct from classical postinfectious gbomeru- inents were carried out with definitive surgical wound closure bonephritis in which the onset of renal disease generally fol- with muscle-flap transposition on day 52 after CABG. Sternal lows the resolution of a self-limiting streptococcal infection. tissue culture was negative by day 42. Urine output began to The clear clinical and histological documentation in this case, increase shortly afterwards and hemodialysis was discontin- as well as the lack of confounding coexisting or preexisting ned. The patient was eventually discharged from hospital to disease, make it an ideal platform for the discussion of what Glomerulonephntis in Acute Osteomyelitis 1635 common histological lesion described in all of the above cases is diffuse endocapillary proliferation, sometimes with mem- branoproliferative features. Extracapillary proliferation and in- terstitial infiltrates may occur. Immune-type deposits have been demonstrated in subendothelial, intramembranous, and subepithelial locations (the latter often as typical “humps”) (3,5,7-10,1 1-13). As regards clinical course and prognosis, in general these cases have in common a lag time of 5 days to 4 weeks between onset of infection and renal disease, as well as a strong dependence of renal recovery on successful treatment of the underlying infection. Chronic renal impairment, varying from mild to severe, usually occurs in the setting of a pro- longed active infection. One series, which also included cases of typical poststreptococcal glomerulonephritis, found that older age, higher serum creatinine concentration, and crescen- tic features on biopsy were predictive of poorer overall and renal survival (5). Glomerulonephritis and Staphylococcal Infections The predominance of staphylococcal infections, regardless of
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