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Kidney Week

Abstract: FR-PO231

Say "No" to the DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms)

Session Information

Category: Acute Kidney Injury

  • 103 AKI: Mechanisms

Authors

  • Miller, Hannah R., University of Kentucky College of Medicine, Lexington, Kentucky, United States
  • Sims, Tyler, University of Kentucky College of Medicine, Lexington, Kentucky, United States
  • Beavin, Sam, University of Kentucky College of Medicine, Lexington, Kentucky, United States
Introduction

Healthy 25-year-old with rash due to DRESS and acute kidney failure due to granulomatous acute interstitial nephritis in the setting of EBV and RSMF infection.

Case Description

A 25-year-old woman with history of paroxysmal SVT and migraines was seen outpatient and treated with amoxicillin/clavulanic acid for suspected bacterial pharyngitis with lymphadenopathy. Four days later, she developed a pruritic rash on hands and shins that spread diffusely. Hospital workup showed positive IgM titers for Rocky Mountain Spotted Fever and IgG titers for Ebstein-Barr Virus. Patient started on topical steroids and doxycycline for suspected RMSF. She then developed flu-like symptoms and oliguria with severe kidney failure.

Kidney function worsened to a peak creatinine of 11.71 mg/dL. Kidney US demonstrated increased parenchymal echogenicity, and UA was unremarkable. Hospital day 4 kidney biopsy showed severe tubular interstitial nephritis with substantial eosinophils in interstitium and formulation of granulomas. She was treated with IV methylprednisolone for 3 days and then switched to oral prednisone with significant improvement in kidney function.

Discussion

This case revealed the rare pathological finding of granulomatous tubulointerstial nephritis on kidney biopsy and rapid improvement of kidney function with high dose steroids. The presentation was mostly likely due to DRESS from the amoxicillin with associated AIN. Cases of AIN with granulomatous inflammation are not common and account for < 1% of all kidney biopsy findings (1). Most often this pattern is associated with antibiotics, NSAIDS and diseases such as sarcoidosis, TB, fungal infections and GPA (Shah S. 2015). Glucocorticoids were the treatment of choice as patient achieved resolution of both her DRESS and acute kidney failure with avoidance of dialysis.

Kidney Biopsy at 20X Magnification