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Acute Tubulointerstitial Nephritis Due to the Use of Rifampicin. Case Report

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Acute Tubulointerstitial Nephritis Due to the Use of Rifampicin. Case Report case reports 2020; 6(1) https://doi.org/10.15446/cr.v6n1.80443 ACUTE TUBULOINTERSTITIAL NEPHRITIS DUE TO THE USE OF RIFAMPICIN. CASE REPORT Keywords: Nephritis; Interstitial; Acute Kidney Injury; Rifampin. Palabras clave: Nefritis intersticial; Lesión renal aguda; Rifampicina. Juan Camilo Motta Camilo Andrés Rodríguez Universidad del Rosario - School of Medicine and Health Sciences - Specialization in Internal Medicine - Bogotá D.C. - Colombia. Camilo Cortes Universidad del Rosario - School of Medicine and Health Sciences - Specialization in Internal Medicine - Bogotá D.C. - Colombia. Hospital Universitario Mayor Méderi - Internal Medicine Service - Bogotá D.C. - Colombia. Jaime Escobar Hospital Universitario Mayor Méderi - Inpatient Department - Bogotá D.C. - Colombia. Corresponding author Juan Camilo Motta. Internal Medicine Service, Hospital Universitario Mayor Méderi. Bogotá D.C. Colombia. Email: [email protected]. Received: 14/06/2019 Accepted: 16/09/2019 acute tubulointerstitial nephritis due to the use of rifampicin. case report RESUMEN ABSTRACT 45 Introducción. La rifampicina es un medicamento Introduction: Rifampin is a cornerstone for fundamental en la primera fase del tratamiento the first phase of the treatment of pulmonary en la tuberculosis pulmonar; sin embargo, esta tuberculosis. This report presents the case of puede causar nefritis tubulointersticial aguda a patient with allergic tubulointerstitial nephritis (NTIA) en raras ocasiones. (ATIN) due to rifampin, situation that has not been reported in Colombia. Presentación del caso. Paciente masculino con antecedentes de tuberculosis y en trata- Case presentation: A male patient with a history miento con rifampicina, quien desarrolló lesión of pulmonary tuberculosis treated with rifampin renal aguda. Al ingreso, el sujeto no registró developed acute kidney injury. On admission, no anormalidades o antecedentes que explicaran evidence of abnormalities or history to explain lesión renal, pero sí presentaba acidosis tubular the injury was found, but he did present tubular y síndrome de Fanconi asociado. La lesión renal acidosis and associated Fanconi syndrome. The concordó temporalmente con el uso de rifampi- kidney injury was temporarily consistent with cina y una biopsia de riñón confirmó NTIA. Se rifampicin use, and a kidney biopsy confirmed ordenó suspender el medicamento, con lo cual ATIN. The drug was suspended, resulting in im- la función renal mejoró. proved kidney function. Discusión. La NTIA como un efecto secundario Discussion: ATIN as a side effect of rifampin de la rifampicina es una enfermedad poco repor- is a scarcely reported disease. The risk of de- tada, por tanto, al iniciar y al reiniciar el manejo veloping this condition should be considered con este medicamento se debe tener en cuenta when starting and restarting treatments with el riesgo de desarrollarla. this medication. Conclusión. La NTIA es uno de los efectos Conclusion: ATIN is one of the side effects secundarios del tratamiento de la tuberculosis y, of tuberculosis treatment. Albeit rare, it should aunque es raro, debe tenerse en cuenta al iniciar be considered when starting tuberculosis el esquema de medicamentos para la tuberculosis. medications. case reports Vol. 6 No. 1: 44-51 46 INTRODUCTION consultation according to the four-drug fixed- dose combination regimen used to treat this Rifampicin is a first-line anti-tuberculosis antibiotic condition (isoniazid, rifampin, pyrazinamide, and drug used to treat Mycobacterium tuberculosis. It either ethambutol or streptomycin). (6) inhibits the β subunit of bacterial RNA polymerase The patient’s kidney function was normal prior with a consequent inhibition of messenger RNA to antituberculosis management and he had (1); its use can generate side effects, including liver no previous exposure to other medications, but and gastrointestinal involvement and acute kidney given the abnormal results of laboratory tests injury, which was reported in 0.05% of patients in regarding kidney function, he was referred to the a retrospective study conducted between 1987 emergency department. On admission, the patient and 1995. (2) Factors associated with increased was in good general condition; hydrated; with- risk of kidney involvement were reintroduction out rashes, fever, dysuria, hematuria, abdominal and intermittent use of rifampicin. (2,3) pain, nausea, vomiting, fatigue, or decreased or The onset of acute kidney injury in patients increased amount of urine; he did not present using rifampicin for the first time has been barely any other symptoms on review of systems, nor reported in the literature. (4) These people have manifested other relevant medical history. Physical a favorable prognosis for recovery of kidney examination revealed heart rate of 78 beats per function, which can range from 73% (5) to 96% minute, respiratory rate of 18 breaths per minute, (2), while mortality can reach up to 1.6%. (2) and blood pressure of 118/68 mmHg. Fist percus- sion was negative and there was no abdominal CASE PRESENTATION pain, edema, or neurological abnormalities. Creatinine test requested by the outpatient A 32-year-old Hispanic male from Venezuela consultation service had values of 4.17 mg/dL. and living in Bogotá D.C., unemployed and On admission, new tests were performed (Table with scarce socioeconomic resources, was 1), which showed elevated azoids, proteinuria admitted to the emergency department of the in non-nephrotic range and metabolic acidosis Hospital Universitario Mayor Méderi after being with increased anion gap; lactic acidosis and referred for outpatient treatment of tuberculo- diabetic ketoacidosis were ruled out as causes sis. Treatment was started one month prior to of these symptoms. Table 1. Laboratory test results on admission. Test Results Blood count Leucocytes: 5 460, neutrophils: 3 750, lymphocytes: 840, eosinophils: 100, hemoglobin: 10.1 mg/dl, hematocrit: 31%, mean corpuscular volume: 83.3fL, mean corpuscular hemo- globin: 32pg, red blood cell distribution width: 16.8%, platelets: 360 000. Urinalysis Specific gravity: 1 008, pH: 5, proteins: 25 mg/dL, glucose: 100 mg/dL, red blood cells: 25xc, leucocytes: 5 xc, scarce bacteria and no eosinophiluria. Electrolytes Sodium: 136 mmol/L, potassium: 4.6 mmol/L, chlorine: 103 mmol/L, magnesium: 2.05 mmol/L. Others Prothrombin time: 16.1 s, thromboplastin time: 23 s, human immunodeficiency virus: nega- tive, hepatitis b surface antigen: negative, hepatitis c antibodies: negative, cultures: negative. Continues. acute tubulointerstitial nephritis due to the use of rifampicin. case report Test Results 47 Arterial blood gases pH: 7.38, partial pressure of oxygen: 86, partial pressure of carbon dioxide: 23, bicar- bonate: 14, base excess: -9.4, lactate 1, ratio of partial pressure arterial oxygen and fraction of inspired oxygen: 415. Additional 24-hour urine protein: 700 mg/dL, urine sodium: 99 meq/L, urine potassium: 19.6 meq/L, urine chlorine: 78.1 meq/L, glucose: 102mg/dL. Immunological Antinuclear antibodies: negative, anti-DNA: negative, anti-LA: negative, anti-RO: neg- ative, anti-SM: negative, anti-RNP: negative, C3: normal, C4: normal, anti-neutrophil cytoplasmic antibodies: negative. Source: Own elaboration. Kidney and urinary tract ultrasound showed involvement compatible with Fanconi syndrome. normal-sized kidneys with diffuse increase in echoge- Considering the acute renal injury with prox- nicity and no loss in corticomedullary differentiation. imal and distal tubular involvement, the history The patient presented acute kidney disease of tuberculosis and that rifampicin is the most KDIGO III (7), glomerular filtration rate of 23.38 frequently involved drug in kidney failure in this mL/min calculated by cockroft, proteinuria in the type of cases (8), treatment was suspended and non-nephrotic range, high anion gap metabolic a kidney biopsy was indicated to confirm the acidosis, urine sediment with glycosuria, positive origin of the failure and plan a treatment. After urine anion gap and normal central glucose. All the suspension of rifampicin, azotemias improved this led to consider that there was proximal tubular until creatinine was normalized (Figure 1). Behavior of creatinine mg/dL 5 4 3 2 1 0 Feb Feb Feb 1Feb 12Feb 1Feb 1Feb 1Feb 2Feb 22Feb 2Feb 2Feb 2Feb 2ar ar ar ar 1ar Behavior of creatinine Figure 1. Behavior of creatinine. Source: Own elaboration. Kidney biopsy confirmed acute tubuloint- hypersensitivity with associated tubular injury erstitial nephritis (ATIN) with inflammatory (Figure 2). cells, eosinophils, and interstitial edema. Figure 2 shows 23 normal glomeruli with The findings were also suggestive of drug normal basement membrane, no mesangial case reports Vol. 6 No. 1: 44-51 48 expansion and no endocapillary or extracapillary vacuolization of the tubular epithelium; and proliferation. Tubulointerstitial findings included: irrelevant vascular findings that did not show interstitial inflammation of the whole cortical area; sclerosis or hyalinosis. presence of mononuclear inflammatory cells Management with prednisolone at 1 mg/kg (++++); eosinophils (++); plasmocytes (++); was initiated with stabilization of kidney function tubulitis (++) with focal rupture; degenerative after 6 weeks. Once creatinine levels normalized changes of the tubular epithelium; detachment, (0.9 mg/dl), the patient was discharged; he flattening and cellular remains at intraluminal continued with antituberculosis treatment and level with some neutrophils; extensive irregular
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