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Kidney Week

Abstract: PO0041

Murine Typhus-Related Thrombotic Microangiopathy, Bilateral Renal Cortical Necrosis, and Acute Disseminated Encephalomyelitis

Session Information

Category: Acute Kidney Injury

  • 101 AKI: Epidemiology, Risk Factors, and Prevention

Authors

  • Agraharkar, Mahendra L., Baylor College of Medicine, Houston, Texas, United States
  • Blanton, Lucas S., University of Texas Medical Branch at Galveston, Galveston, Texas, United States
  • Bhatt, Radheshyam, University of Texas Medical Branch at Galveston, Galveston, Texas, United States
  • Afrouzian, Marjan, University of Texas Medical Branch at Galveston, Galveston, Texas, United States
Introduction

Thrombotic Microangiopathy (TMA), Bilateral Renal Cortical Necrosis (BRCN) and Acute Disseminated Encephalomyelitis (ADEM) are rare complications of infections. Murine Typhus (MT), a mild rickettsial infection rarely involves kidneys. We present a young male with rash, anuric renal failure, schistocytes, elevated LDH and high IgG and IgM levels for MT. A CT scan and renal biopsy revealed TMA and BRCN. A week after treatment he developed seizures from ADEM. MT should be considered in unexplained TMA, BRCN or ADEM in endemic area.

Case Description

A 22-yr-old male admitted with truncal rash, vomiting and anuria for 5 days. His admission platelet count was141k/ul with 1+ schistocytes. His Sodium was 128, Potassium 5.8, Chloride 82, and HCO3 13 all in mEq/L. His BUN was 200, creatinine 20 and LDH 4232 U/L. Complement levels, ANA and anti DNA, blood cultures, viral serologies for most viruses including SARC-COV-19 IgG were negative. ADAMTS-13 activity was 61%. MT antibodies titers were >1:1024 for both IgG and IgM. A CT scan and renal biopsy revealed severe BRCN. The glomeruli and arterioles contained microthrombi. IF revealed bright staining fibrinogen in the lumen, endothelium and walls of arterioles and arteries. EM revealed endothelial cell injury and necrosis, and fragmented red cells under the endothelium. He was effectively treated with doxycycline but later he developed encephalopathy and seizures.

Discussion

MT is a mild infection caused by Rickettsia typhi transmitted by rat and cat fleas and is endemic to Texas, California and Hawaii in the US. MT is mostly self limiting and mild. In severe cases MTpresents with renal, neurologic, hepatic, cardiac and pulmonary symptoms. Renal dysfunction is due to interstitial nephritis or ATN from renal hypoperfusion. RCN is a rare cause of AKI encountered in 1-2 percent of all cases of AKI. ADEM or post infectitious encephalomyelitis is a rare neurologic complication triggered by vaccinations and infections. Recently authors published a case of MT with collapsing glomerulopathy likely a result of TMA.
In our patient the only identifiable infection was MT, which usually is a mild infection. We report a case of MT causing BRCN, TMA and ADEM. We suggest that MT should be cosidered in multiorgan involment the endemic area when no other cause is identified.