Page 20 - Delaware Medical Journal - August, 2016
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Crystal Induced Acute Kidney Injury
Efua Asamoah-Odei, MD CASE PRESENTATION
A 52-year-old male with a medical history of hepatitis C and HIV diagnosed 15 years ago presented with a two-day history of hematuria and reduced urine output. He had recently been hospitalized with new onset seizures and had been discharged home two days prior.
During the prior hospitalization, he was found to have a left frontal brain mass and had a craniotomy and excision. Pathology showed positive toxoplasmosis by both immunohistochemical staining and polymerase chain reaction (PCR), while blood samples were toxoplasma IgG titer positive. Hence he was discharged on a seven-day course of sulfasalazine 1500mg every 6 hours, pyrimethamine 75mg daily, and leucovorin 24mg daily. His other medications were hydrochlorothiazide, Lisinopril, levetiracetam, abacavir, dolutegravir and lamivudine. He had been on ritonavir and darunavir three months ago.
severe, and non-radiating. Over the next two days, he was unable to urinate and was only passing blood. He denied any other associated symptoms including dysuria, fevers, chills, nausea, or vomiting.
In the emergency department, his serum creatinine was 4.18, increased from his baseline of 0.7mg/dl two days prior. He had no prior history of renal disease. He denied any NSAID use or use of any other over-the-counter medications.
A computed tomography scan of the abdomen- kidney protocol was performed. It revealed bilateral nephrolithiasis at the vesicoureteral junction and left proximal ureter with evidence of perinephric stranding, left sided moderate hydronephrosis and mild right sided hydronephrosis (Figure 1). Abdominal ultrasound six months prior had shown normal kidneys with no evidence of renal calculi.
Urinalysis with microscopy revealed a pH of 5.5, numerous red blood cells, and amorphous crystals.
Sulfasalazine crystalluria induced acute kidney injury was suspected at this point and sulfasalazine was stopped. The of sodium bicarbonate. His urine output started to increase and the hematuria resolved. Repeat urinalysis showed a pH
of 7.0 on day two of his hospitalization. Serum creatinine at that time was 2.0 mg/dl, and further decreased to 1.0mg/dl
FIGURE 1
CT-scan showing bilateral hydronephrosis.
In general, correction of volume depletion with isotonic fluids
and cessation of the offending drug are the mainstays of treatment in drug induced crystalluria.
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Del Med J | August 2016 | Vol. 88 | No. 8
