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The Brief Case: Postinfectious Glomerulonephritis as an Unexpected Sequela of Drinking Raw Milk

CASE A 13-year-old female with a history of Henoch-Schönlein purpura (HSP; IgA vasculitis) at 15 months of age and recurrent urinary tract infections during age 8 to 9 years presented to her primary care physician (PCP) with complaints of 1 day of hematuria, left side flank pain, and a fever of 38.9°C. She was subsequently referred to the emergency department for further care. Her white blood cell (WBC) count was within normal limits (12,000 WBC/ l; reference range, 4,500 to 13,000 WBC/ l), and she had an elevated C-reactive protein level of 4.5 mg/dl (reference range, 0 to 1.0 mg/dl) and creatinine level of 1.1 mg/dl (reference range, 0 to 1.0 mg/dl). A clean-catch urine specimen was sent for urinalysis and culture. The urine was noted to be cloudy and brown with 300 mg/dl protein, 15 mg/dl ketones, and nitrites present. There were 250 red blood cells and 20 to 50 WBCs per high-power field. Her urine culture grew 100,000 CFU/ml of mixed Gram-positive flora, defined in our laboratory as 3 organisms without a predominant uropathogen. The urine culture results indicated a contaminated specimen. A single blood culture composed of one aerobic and one anaerobic bottle (VersaTREK REDOX 1 and REDOX 2; Thermo Fisher Scientific, Waltham, MA) was also collected in the emergency department. A renal ultrasound was performed and showed bilateral nonspecific increased echogenicity in the kidneys. The patient was administered a dose of ceftriaxone and admitted for further evaluation with a presumed diagnosis of pyelonephritis. Ceftriaxone was continued during her admission. The patient’s creatinine levels increased to 1.6 mg/dl and 1.9 mg/dl during the 2 days after admission, and her diagnosis was updated to glomerulonephritis. Thirty-two hours after collection, the aerobic blood culture bottle signaled positive. No organisms were seen on Gram stain, so an acridine orange (AO) stain was performed, which revealed curved seagull-shaped rods (Fig. 1A). Upon review of the Gram stain, very faint curved Gram-negative rods were seen (Fig. 1B). The positive blood culture broth was subsequently subcultured per standard protocol to blood agar, chocolate agar, and MacConkey agar. Additionally, due to the suspicion of Campylobacter sp. or, less likely, Helicobacter sp., the blood culture broth was subcultured to two plates each of cefoperazone-vancomycin-amphotericin B (CVA) agar and chocolate agar. One set of plates was incubated under microaerobic conditions at 42°C (GasPak EZ CampyPouch system; Becton, Dickinson and Company, Franklin Lakes, NJ), and the second set of plates was incubated under anaerobic conditions at 35°C. Growth was only observed on the CVA and chocolate agar plates incubated under microaerobic conditions at 42°C. Colonies were wet and spready, with a slight brown hue (Fig. 2). Colonies were subjected to matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS; Bruker Daltonics, Inc., Billerica, MA), and the isolate was identified as Campylobacter jejuni, with scores of 2.19 and 2.21 using the Biotyper-CA claim 2 in vitro diagnostic (IVD) library. The identification was reported, Citation Whitworth MS, Pence MA. 2019. The Brief Case: Postinfectious glomerulonephritis as an unexpected sequela of drinking raw milk. J Clin Microbiol 57:e01767-18. https://doi.org/ 10.1128/JCM.01767-18. Editor Carey-Ann D. Burnham, Washington University School of Medicine Copyright © 2019 American Society for Microbiology. All Rights Reserved. Address correspondence to Morgan A. Pence, morgan.pence@cookchildrens.org. For answers to the self-assessment questions and take-home points, see https://doi.org/10.1128/ JCM.01790-18 in this issue. Published THE BRIEF CASE