acyclovir and Nephritis--Interstitial

We report what we believe to be the first two cases of acute interstitial nephritis associated with vancomycin and ceftriaxone therapy in adults. A 40-year-old man with a medical history of traumatic brain injury and tonic-clonic seizure disorder was admitted to the hospital with a seizure episode and temperature of 103 degrees F. He was administered ceftriaxone, vancomycin, and acyclovir for suspected bacterial and/or viral meningitis. On day 4, the patient was noted to have diffuse erythematous plaques on the neck, chest, arms, abdomen, and back, as well as an elevated serum creatinine level of 3.1 mg/dl (baseline 0.9 mg/dl) and an elevated eosinophil count (6%). Dermatology and renal consultations were obtained, and a diagnosis of suspected acute interstitial nephritis was made. After a 3-day course of antibiotic treatment (day 4 of hospitalization), all antibiotics were discontinued and topical triamcinolone 0.1% ointment and hydrocortisone 2.5% cream were begun for the rash. The patient was discharged 5 days later with improvement in the rash, serum creatinine level (1.0 mg/dl), and eosinophil count (0.9%). A 59-year-old woman with a medical history of diabetes mellitus was admitted to the hospital with a serum creatinine level of 3.7 mg/dl, eosinophil count of 8.4%, and fractional excretion of sodium of 2.94%. The patient had been receiving treatment with vancomycin and ceftriaxone for osteomyelitis for 28 days before this hospital admission. Her baseline serum creatinine level (before antibiotic therapy) was 1.0 mg/dl. Renal consultation was obtained, and a diagnosis of probable acute interstitial nephritis was made. Ceftriaxone and vancomycin were discontinued, and her serum creatinine level gradually decreased to 3.3 mg/dl and then further to 1.5 mg/dl over the next 3 months. Use of the Naranjo adverse drug reaction probability scale revealed that the adverse reaction was possible in the first case and probable in the second case. Health care professionals need to be cognizant that drug-induced acute interstitial nephritis can be associated with concomitant administration of ceftriaxone and vancomycin therapy. Early detection of this rare adverse reaction is paramount in order to prevent acute renal insufficiency.

Topics: Acute Disease; Acyclovir; Adult; Anti-Bacterial Agents; Antiviral Agents; Ceftriaxone; Drug Therapy, Combination; Female; Humans; Injections, Intravenous; Male; Meningitis, Bacterial; Meningitis, Viral; Middle Aged; Nephritis, Interstitial; Vancomycin

Severe renal disease in the setting of Epstein-Barr virus (EBV) infection is exceedingly rare. We report here the case of a 22-year-old man with acute EBV infection associated with severe interstitial nephritis. The patient developed chronic fatigue and chronic renal failure with a serological profile typical of primary EBV infection. Clinical improvement with anti-EBNA seroconversion occurred after acyclovir therapy. Our patient illustrates that chronic fatigue with major organ dysfunction and a serological profile of primary infection can be seen in chronic EBV infection. In such a case, acyclovir may prove beneficial.

Topics: Acyclovir; Adult; Antiviral Agents; Chronic Disease; Fatigue Syndrome, Chronic; Humans; Infectious Mononucleosis; Male; Nephritis, Interstitial

Forty-six days after renal transplantation for inborn tubulointerstitial nephropathy, an 18-year-old man was rehospitalized for renal failure with creatinine at 200 mumol/l. There was no sign of infection and ciclosporin level was within therapeutic range. Transplant biopsy showed minor interstitial infiltration with mononucleated cells. Methylprednisolone by 10 mg/kg/d bolus did not improve renal function and OKT3 5 mg/d was substituted for ciclosporin but had to be stopped on day 8 because of a severe infectious syndrome. The patient developed fever (39 degrees C), erythemato-pultaceous pharyngitis followed by major multiple lymph node and spleen enlargement. The diagnosis of primary Epstein-Barr infection was confirmed serologically. Histology of a submaxillary lymph node reported monomorphic immunoblastic lymphoproliferation. Immunologic phenotyping showed CD19, CD20 and CD22 surface antigens characteristic of B cells and in situ Epstein-Barr hybridization was positive in 100% of the cells. Southern Blot showed an oligoclonal pattern. Ciclosporin and azathioprin were stopped and the patient was treated with corticosteroids (15 mg/d) and aciclovir given orally (3.2 g/d) for 3 months. Outcome at six months was favorable with normalization of the renal function and complete regression of the infectious syndrome. This case demonstrated the importance of molecular biology techniques for virologic and genotypic assessment of lymphomatous proliferation allowing positive aetiologic diagnosis.

Topics: Acyclovir; Adolescent; Blotting, Southern; Herpesviridae Infections; Herpesvirus 4, Human; Humans; In Situ Hybridization; Kidney Transplantation; Lymphoproliferative Disorders; Male; Nephritis, Interstitial; Postoperative Complications; Tumor Virus Infections

Two patients with presumed herpes simplex encephalitis developed severe non-oliguric acute renal failure shortly after acyclovir infusions. Renal function returned to normal in less than 3 weeks after discontinuation of acyclovir. Renal biopsies done during the acute phase demonstrated interstitial oedema, eosinophils and cellular aggregates in both and granulomata in the second case suggesting acyclovir-induced hypersensitivity interstitial nephritis.

Topics: Acyclovir; Adult; Encephalitis; Female; Humans; Male; Middle Aged; Nephritis, Interstitial