Tubulointerstitial Diseases

35. A 67-year-old black man with a history of tobacco abuse and ethanol abuse is
admitted for gradually
worsening esophageal dysphagia complicated by a 1-day history of shortness of
breath, productive
cough, and fever. On examination, the patient has a temperature of 101.5 F (38.6
C); he is tachypneic
and has signs of consolidation in his right posterior lung field. Chest radiography
reveals a right lower
lobe infiltrate consistent with aspiration pneumonia. He is placed on piperacillintazobactam and oxygen, and he gradually improves. By hospital day 3, he experiences defervescence,
but on hospital day 10
he is noted to again have a fever (100.8 F [38.2 C]). In addition, the patient has a
rash, and peripheral
blood eosinophilia and acute renal insufficiency are present.
Which of the following statements concerning this patient's condition is most
correct?
A. This patient will likely progress to end-stage renal disease
10 NEPHROLOGY 21
B. Standard of care would include stopping the piperacillin-tazobactam and starting high-dose I.V. solumedrol
C. Another -lactam antibiotic can be safely substituted for piperacillin
D. Urinalysis will most likely reveal sterile pyuria, mild proteinuria,
and hematuria
E. Most patients with this disorder become oligoanuric
Key Concept/Objective: To understand the clinical manifestations and management
of acute
interstitial nephritis (AIN)

Virtually all -lactam antibiotics (i.e., penicillins and cephalosporins) can produce
AIN.
It usually occurs after several weeks of high-dose antibiotic therapy. Classically,
patients
exhibit a triad of hypersensitivity reactions: rash, fever, and eosinophilia. The
secondary fever associated with AIN usually occurs after defervescence from the original
infectious disease and during the onset of the allergic reaction. Urinary findings in
patients
with AIN include the nonspecific findings of sterile pyuria and mild proteinuria, as
well
as the more significant finding of hematuria, which in some patients may be gross.
Eosinophils may be found in the urine sediment on Wright or Hansel staining in over
75% of cases. The pathogenesis of -lactam-associated AIN remains unknown. The
disease is not dose related and occurs in only a small number of the millions of people
taking -lactam drugs each year. It can recur or be exacerbated on rechallenge with a
second -lactam drug. -Lactam-associated AIN is treated by discontinuing the drug
and
avoiding other -lactam antibiotics. Most patients regain renal function, and many
regain baseline renal function. Only a minority of patients with AIN are oliguric. The
use of corticosteroids to treat renal failure associated with AIN remains
controversial.
No randomized, controlled trials have yet proved that corticosteroid therapy has any
advantages over discontinuance of medication. (Answer: DUrinalysis will most
likely
reveal sterile pyuria, mild proteinuria, and hematuria)