Interestingly, in 2012, Forbes et al

Interestingly, in 2012, Forbes et al. serum creatinine, not determined, Intravenous immunoglobulin Open in a separate window Fig. 1 Low esophageal two-chamber view. Shown is large vegetation (arrow) on the Xanthone (Genicide) posterior leaflet of the mitral valve, which prolapses into the left ventricle during sistole Open in a separate window Fig. 2 Three-dimensional trans-esophageal view of the mitral valve C viewed from the atrial side. Shown is large branched vegetation (asteriks), which adheres to the P2 scallop of the posterial mitral leaflet The pathohistological report of the kidney biopsy revealed uneven proliferative (70%), exudative (32%), necrotizing (10%) and crescentic (13%) glomerulonephritis with mixed inflammatory interstitial infiltration. Immunofluorescence showed glomerular deposits of C3, IgG and IgM, suggesting infection-related immunocomplex GN (Fig.?3). Electron microscopy confirmed electron dense mesangial and segmental subendothelial deposits, without large subepithelial deposits (humps) usually found in infection-related GN. Open in a separate window Fig. 3 Diffuse proliferative glomerulonephritis (a) with focal glomerular necrosis Keratin 18 (phospho-Ser33) antibody (b) and extracapillary crescent formation (c) in 13% glomeruli Given our uncertainty of reliably excluding an ANCA driven mechanism of disease, high dose methylprednisolone was introduced (3 pulses 7?mg/kg bw followed by oral methylprednisolone 0.8?mg/kg bw for 1?month with stepwise lowering and exclusion after the second biopsy), which resulted in a gradual improvement of kidney function and general condition. A week later, the patient underwent elective surgical treatment of mitral valve endocarditis. Mitral valve repair with resection of Xanthone (Genicide) the P1-P2 Xanthone (Genicide) scallops and mitral valve annuloplasty was performed. After the surgical intervention, his kidney function further improved. At discharge (1?month after the mitral valve operation) his serum creatinine (131 umol/l) and PR3-ANCA titer (32?IU/mL) were still increased, while blood cryoglobulin level had normalized (

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