CLINICAL IMAGE
Acute interstitial nephritis: a multifaceted disease Gajapathiraju Chamarthi1, Mayanka Kamboj1, Olanrewaju A. Olaoye1, Xu Zeng2 & Abhilash Koratala1 1
Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida Division of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
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Correspondence Abhilash Koratala, Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, P.O. Box 100224, Gainesville, FL 32610. Tel: +1-352-294-8694; Fax: +1-352-392-3581; E-mail:
[email protected]
Key Clinical Message
Funding information No sources of funding were declared for this study.
Keywords
Drug-induced acute interstitial nephritis is an important cause of unexplained acute kidney injury in hospitalized patients. It can present with nonspecific clinical features, and renal biopsy should be considered for definitive diagnosis. Removal of the offending agent along with early initiation of corticosteroid therapy is the mainstay of treatment.
Acute kidney injury, renal biopsy, steroid.
Received: 27 December 2017; Accepted: 9 February 2018
doi: 10.1002/ccr3.1456
Case A 21-year-old otherwise healthy White woman was admitted to the hospital for treatment of atypical pneumonia following foreign travel. She was started on ceftriaxone and azithromycin to complete a 9-day course of
antibiotics. She developed acute kidney injury (AKI) with sudden worsening of serum creatinine from 0.98 mg/dL to 4.36 mg/dL on day 4, eventually requiring hemodialysis (Fig. 1). The primary clinical diagnosis was acute tubular necrosis in the setting of sepsis. There was no rash, eosinophilia, pyuria, or eosinophiluria suggestive of
Figure 1. Graph depicting the trend of patient’s serum creatinine and major clinical events. ª 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
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Acute interstitial nephritis
(A)
G. Chamarthi et al.
(B)
Figure 2. Renal biopsy demonstrating (A) normal glomerulus, which excludes glomerulonephritis; (B) diffuse interstitial inflammation, suggestive of AIN. Eosinophils are shown in the inset, which favor drug-induced etiology.
acute interstitial nephritis (AIN). Moreover, the timing of creatinine up-spike was not typical for AIN. Glomerulonephritis was unlikely in the absence of hematuria and significant albuminuria. Interestingly, renal biopsy was consistent with drug-induced AIN (Fig. 2). She was started on steroid therapy with complete recovery of renal function in 6 weeks. AIN typically develops 7–10 days after drug exposure and presents with variable clinical features [1]. High index of suspicion for AIN should be maintained, even in the absence of “classic triad” of fever, rash, and eosinophilia [2]. Definitive diagnosis often requires renal biopsy [1, 2]. In addition to prompt withdrawal of the offending agent, early initiation of corticosteroids has shown to be beneficial in improving renal outcomes, especially in severe cases [3, 4].
Informed Consent Informed consent has been obtained for the publication of this clinical image.
Conflict of Interest The authors have declared that no conflict of interest exists.
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Authorship All the authors: made substantial contribution to the preparation of this manuscript. RC and MK: drafted the manuscript and performed literature search. OAO: provided input on patient management. XZ: provided pathology images and pertinent input. AK: revised the manuscript critically for important intellectual content as the attending physician on the case. References 1. Rossert, J. 2001. Drug-induced acute interstitial nephritis. Kidney Int. 60:804–817. 2. Koratala, A., R. Khan, and X. Zeng. 2017. Silent acute interstitial nephritis: suspicion is the key to diagnosis. Am. J. Med. doi: 10.1016/j.amjmed.2017.11.016. pii: S0002-9343 (17)31208-1. 3. Qadri, I., X. Zeng, R. Guo, and A. Koratala. 2017. Acute interstitial nephritis and DRESS syndrome without eosinophilia associated with cefepime. BMJ Case Rep. doi: 10.1136/bcr-2017-221401. pii: bcr-2017-221401. 4. Gonzalez, E., E. Gutierrez, C. Galeano, C. Chevia, P. de Sequera, C. Bernis, et al. 2008. Early steroid treatment improves the recovery of renal function in patients with drug-induced acute interstitial nephritis. Kidney Int. 73:940–946.
ª 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
