Case Presentation: A 70 year old man with past medical history of prostate cancer, s/p prostatectomy and radiation therapy, CVA requiring tPA treatment and diet controlled diabetes was seen initially at an outside medical facility with complaints of decreased appetite, weight loss and fatigue . His physical exam was only remarkable for a purpuric rash on his medial thighs. He had  extensive work up which was reported to be inconclusive. He later transferred to our hospital for progressive renal failure when serologies were repeated and were mostly unremarkable except for non-hemolytic anemia, a slightly decreased C3, positive rheumatoid factor with normal CCP Ab, and Type III cryoglobulinemia. Skin biopsy was performed and showed leukocytoclastic vasculitis. He was then initiated on high dose steroids with a concern of cryoglobulemic vasculitis. Thereafter patient quickly deteriorated and developed clinical signs of sepsis. Kidney biopsy revealed diffuse proliferative necrotizing glomerulonephritis with crescents and immune complex deposition. Blood cultures obtained now were positive for streptococcus viridans. Further imaging was obtained showing mitral valve endocarditis. His course was further complicated by multi-organ failure requiring dialysis, CNS vasculitis with subarachnoid hemorrhage, DIC, PEG for enteral nutrition, perforated viscus requiring exploratory laparotomy, respiratory failure and eventual tracheostomy. Once the patient was started on appropriate antibiotics, he slowly improved and eventually underwent mitral and tricuspid valve repair for severe regurgitation.  

Discussion: In this report we discuss a case presenting as a primary immunologic disorder, while the underlying culprit was a subacute infection. The lack of fever and leukocytosis, the typical signs of infection, was the most interesting and confusing presentation of our case which led to this complex series of events. The sudden deterioration of the clinical condition following administration of immunosuppressive therapy uncovered the underlying infection.

Immune complex deposition triggered by bacteremia is a well known phenomenon in IE. Our patient ‘s presentation was dominated by purpuric rash and glomerulonephritis, vasculitis and cryoglobulinemia. This confusing presentation led to a delay in the diagnosis and treatment of the actual infection and hence the complications.

Conclusions: Type III cryoglobulinemia and/ or leukocytoclastic vasculitis should warrant an infectious workup. The absence of fever and/or leukocytosis does not eliminate the possibility of infection. Making the right diagnosis in a timely manner, especially in atypical presentations like our case can reduce morbidity and mortality for patients.