Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Acute Interstitial Nephritis Secondary To NSAID Use in A Patient With Concurrent
Streptococcal Infection
Bajwa, S., D.O.
St. Michael’s Medical Center, Newark, NJ
Introduction: AIN (cute interstitial nephritis) constitutes 10-15% of kidney disease. It is
described as abrupt deterioration in renal function characterized histopathologically as
inflammation and edema in the renal interstitium, with involvement of the renal tubules.
Etiologies include, hypersensitivity reaction, infection, systemic disease, and transplant
rejection. This patient presented with AIN subsequent to use of non steroidal analgesic
use, and streptococcal infection.
Case: 24 year old African American Female with a past medical history of childhood
asthma presented to our hospital with a several day history of diffuse body aches and
decreased urination, with associated abdominal pain, nausea, emesis and diarrhea. Her
pain was located in the right upper quadrant and epigastric area; and described as a
sharp pain that came and went. It was rated at a 6/10 on the pain scale. The emesis
was described as non bloody, non bilious, occurring after ingestion of food, and
consisting mostly of undigested food particles. Her diarrhea was watery, profuse, non
bloody, and not black in color. She stated that each year around the same time she
develops a sore throat with cough requiring treatment with antibiotics. She could not
recall exacerbating or relieving factors. Several weeks prior, she had participated in
heavy ingestion of alcohol on several occasions. At that time she did not feel well and
began self medicating over the counter cold medication and non steroidal antiinflammatory
medications, which she admitted to taking on a regular basis. Labs on
admission showed acute kidney injury with a blood urea nitrogen and creatinine of 25
and 3.4 respectively, no eosinophilia was noted, and the urinalysis showed red color, 3
plus blood, 3 plus protein, 2 plus leukocyte esterase, and greater than 50 white blood
cells. Soon after admission the patient became tachycardia and tachypneic, and began
to desaturate. She was subsequently intubated secondary to fluid overload. At that time
chest x-ray showed frank pulmonary edema and cardiomegally. An autoimmune work
up was negative. Streptozyme was found to be positive. Renal function rapidly
continued to decline. A CT guided renal biopsy was done and the results showed acute
interstitial nephritis. The patient was started on steroids and hemodialysis and her
condition improved.
Discussion: The presentation of AIN can vary somewhat depending on the particular
cause. The classic presentation is symptoms of acute renal failure, with the triad of
fever, skin rash, and arthralgias. Labs will most often show acute renal failure with a
urinalysis showing increased leukocytes, eosinophiluria, proteinuria, red blood cells,
white blood cells, and white blood cell casts. Because presentation can vary, a thorough
investigation for cause of acute renal failure is necessary. Often times, when caused by
NSAIDs, the the classic triad is not seen. The gold standard for diagnosis of AIN is renal
biopsy.