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Acute kidney injury: Finding a needle in a haystack
EJINME-03378; No of Pages 2 European Journal of Internal Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Acute kidney injury: Finding a needle in a haystack Fouad Amraoui ⁎, Sander W.M. Keet, Niels H. Schut Department of Internal Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
a r t i c l e
i n f o
Article history: Received 20 July 2016 Accepted 30 September 2016 Available online xxxx
1. Case An 80-year-old woman with a history of venous thromboembolism and ischemic stroke was admitted with headache and confusion. Examination revealed fever and an altered mental status, but was otherwise unremarkable. Laboratory tests showed normal electrolytes and kidney function and no signs of inflammation. Urine analysis, chest X-ray and imaging of the brain with CT scan showed no explanation for the fever or confusion. Intravenous treatment with cefuroxime 1500 mg and gentamycin 350 mg was immediately started at admission. Cerebrospinal fluid analysis showed a slightly elevated leukocyte
count (9 cells/μl, reference: b 5 cells/μl). Intravenous acyclovir (10 mg/kg every 8 h) was initiated to target viral encephalitis and antibiotics were switched to target a possible bacterial meningitis with ceftriaxone 2 g bidaily and amoxicillin 2 g every four hours. Acyclovir was stopped the next day after PCR was negative for herpes simplex and varicella zoster. The internal medicine was consulted 6 days later because of anuria and a sudden rise in plasma creatinine. The urinary catheter contained 20 cm3 of urine, which was evaluated by light microscopy (Fig. 1). What is your diagnosis?
Fig. 1. Microscopic urinalysis showing two needle shaped structures. The lower needle lies on top of a leukocyte cast and erythrocytes are visible throughout the sample.
⁎ Corresponding author. E-mail address: [email protected] (F. Amraoui).
http://dx.doi.org/10.1016/j.ejim.2016.09.032 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Amraoui F, et al, Acute kidney injury: Finding a needle in a haystack, Eur J Intern Med (2016), http://dx.doi.org/10.1016/ j.ejim.2016.09.032
e2
F. Amraoui et al. / European Journal of Internal Medicine xxx (2016) xxx–xxx
2. Diagnosis The needle-shaped crystals presented in Fig. 1 are pathognomonic for acyclovir crystal-induced acute kidney injury [1,2]. The lower needle lies on top of a leukocyte cast and erythrocytes are visible throughout the sample. Although the patient received only one day of treatment with acyclovir, the risk of crystal formation is higher in dehydrated patients. Considering that the patient had fever and confusion at admission in combination with weight gain and thirst in the following days, it seems likely that dehydration contributed to crystal formation. The differential diagnosis included nephrotoxicity by antibiotics including gentamycin. However, gentamycin-induced renal insufficiency is usually non-oliguric and not accompanied by hematuria. Despite supportive therapy with hyperhydration and loop diuretics to wash out the obstructing crystals, hemodialysis was required on
day 10 after admission. Renal function recovered in the following days and the patient could be discharged on day 18 after admission. Conflict of interest The authors have no conflict of interest to declare. Acknowledgments We have received no funding for this report. All authors have read and approved the final submitted manuscript. References [1] Sawyer MH, Webb DE, Balow JE, Straus SE. Acyclovir-induced renal failure. Clinical course and histology. Am J Med 1988;84:1067. [2] Mason WJ, Nickols HH. Crystalluria from acyclovir use. N Engl J Med 2008;358, e14.
Please cite this article as: Amraoui F, et al, Acute kidney injury: Finding a needle in a haystack, Eur J Intern Med (2016), http://dx.doi.org/10.1016/ j.ejim.2016.09.032
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Acute kidney injury: Finding a needle in a haystack Fouad Amraoui ⁎, Sander W.M. Keet, Niels H. Schut Department of Internal Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
a r t i c l e
i n f o
Article history: Received 20 July 2016 Accepted 30 September 2016 Available online xxxx
1. Case An 80-year-old woman with a history of venous thromboembolism and ischemic stroke was admitted with headache and confusion. Examination revealed fever and an altered mental status, but was otherwise unremarkable. Laboratory tests showed normal electrolytes and kidney function and no signs of inflammation. Urine analysis, chest X-ray and imaging of the brain with CT scan showed no explanation for the fever or confusion. Intravenous treatment with cefuroxime 1500 mg and gentamycin 350 mg was immediately started at admission. Cerebrospinal fluid analysis showed a slightly elevated leukocyte
count (9 cells/μl, reference: b 5 cells/μl). Intravenous acyclovir (10 mg/kg every 8 h) was initiated to target viral encephalitis and antibiotics were switched to target a possible bacterial meningitis with ceftriaxone 2 g bidaily and amoxicillin 2 g every four hours. Acyclovir was stopped the next day after PCR was negative for herpes simplex and varicella zoster. The internal medicine was consulted 6 days later because of anuria and a sudden rise in plasma creatinine. The urinary catheter contained 20 cm3 of urine, which was evaluated by light microscopy (Fig. 1). What is your diagnosis?
Fig. 1. Microscopic urinalysis showing two needle shaped structures. The lower needle lies on top of a leukocyte cast and erythrocytes are visible throughout the sample.
⁎ Corresponding author. E-mail address: [email protected] (F. Amraoui).
http://dx.doi.org/10.1016/j.ejim.2016.09.032 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Amraoui F, et al, Acute kidney injury: Finding a needle in a haystack, Eur J Intern Med (2016), http://dx.doi.org/10.1016/ j.ejim.2016.09.032
e2
F. Amraoui et al. / European Journal of Internal Medicine xxx (2016) xxx–xxx
2. Diagnosis The needle-shaped crystals presented in Fig. 1 are pathognomonic for acyclovir crystal-induced acute kidney injury [1,2]. The lower needle lies on top of a leukocyte cast and erythrocytes are visible throughout the sample. Although the patient received only one day of treatment with acyclovir, the risk of crystal formation is higher in dehydrated patients. Considering that the patient had fever and confusion at admission in combination with weight gain and thirst in the following days, it seems likely that dehydration contributed to crystal formation. The differential diagnosis included nephrotoxicity by antibiotics including gentamycin. However, gentamycin-induced renal insufficiency is usually non-oliguric and not accompanied by hematuria. Despite supportive therapy with hyperhydration and loop diuretics to wash out the obstructing crystals, hemodialysis was required on
day 10 after admission. Renal function recovered in the following days and the patient could be discharged on day 18 after admission. Conflict of interest The authors have no conflict of interest to declare. Acknowledgments We have received no funding for this report. All authors have read and approved the final submitted manuscript. References [1] Sawyer MH, Webb DE, Balow JE, Straus SE. Acyclovir-induced renal failure. Clinical course and histology. Am J Med 1988;84:1067. [2] Mason WJ, Nickols HH. Crystalluria from acyclovir use. N Engl J Med 2008;358, e14.
Please cite this article as: Amraoui F, et al, Acute kidney injury: Finding a needle in a haystack, Eur J Intern Med (2016), http://dx.doi.org/10.1016/ j.ejim.2016.09.032