Professional Documents
Culture Documents
Quiz Page MARCH 2016: A 60-Year-Old Man With Fever, Night Sweats, and Acute Kidney Injury
Quiz Page MARCH 2016: A 60-Year-Old Man With Fever, Night Sweats, and Acute Kidney Injury
MARCH 2016
QUIZ PAGE
DISCUSSION
- What does the kidney
biopsy specimen
demonstrate?
Microscopic examination demon-
strates diffuse interstitial inflam-
matory cell infiltrates, including
numerous plasma cells (Fig 1;
black arrow) and scattered eosin-
ophils (red arrow). The glomer-
ulus (blue arrow) is unremarkable.
There is active tubulitis and
diffuse acute tubular injury. These
histologic features confirm a
Figure 1. Light microscopy of kidney biopsy specimen stained with hematoxylin and
diagnosis of severe diffuse acute eosin (original magnification, 340).
interstitial nephritis (AIN). No
immunoglobulin G4 (IgG4)-
positive cells were observed on implicated as a cause of AIN; in our care providers of this important
immunofluorescence or immuno- patient, the drug also was started association.1-4 A 2012 review
peroxidase staining. after the onset of illness and did not of PPI overutilization does not
alter its progression. Infection-, include AIN in the list of poten-
autoimmune-, TINU-, and IgG4- tial side effects.5
- What are the possible and related causes were excluded in
most likely causes of this this case. - Are the onset and
patient’s kidney injury? PPIs are the second most systemic symptoms
Urinary and kidney biopsy findings commonly administered drug consistent with the
are consistent with a diagnosis class in the United States. The first diagnosis?
of AIN. Historically, the most reported case of PPI-associated
There is a broad range between
common causes of AIN are medi- AIN occurred in 1992, and since
PPI exposure and onset of signs
cations, including antibiotics then, more than 100 similar cases
and symptoms, from hours to as
(beta-lactams, sulfonamides, and have been reported.1-4 Although
long as 12 months.1-4 Case reports
rifampicin) and NSAIDs. Howev- the incidence of PPI-associated
note that the presence of systemic
er, more recently, there have been AIN is low, the prevalence of
inflammatory symptoms occur in
increasing reports of proton pump PPI use dictates that increasing
as many as 39% of patients
inhibitor (PPI)-associated AIN.1-4 numbers of cases will be
with PPI-associated AIN.1,4 The
Other etiologic possibilities include encountered. Simpson et al2
delayed onset and nonspecific
infections, autoimmune conditions calculated an approximate inci-
systemic inflammatory symptoms
(Sjögren syndrome and systemic dence of AIN due to PPIs
that often accompany this entity
lupus erythematosus), tubular at 8 events/100,000 patient-years.
can obscure the diagnosis.
interstitial nephritis with uveitis PPIs are now the most frequent
syndrome (TINU), and IgG4- cause of drug-associated AIN
related tubulointerstitial nephritis. in New Zealand, Australia, and - How should this patient
Our patient had not received com- the United States.1-3 Notwith- be treated?
QUIZ PAGE
QUIZ PAGE