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Cefepime induced acute interstitial nephritis--a case report.

Mac K, Chavada R, Paull S, Howlin K, Wong J - BMC Nephrol (2015)

Bottom Line: Renal function improved only partially with conservative management without any corticosteroid use.Although cefepime has been considered to be a safe antibiotic from nephrotoxicity point, like other cephalosporins this adverse effect can occur rarely.Physicians need to be mindful of nephrotoxicity associated with its use and careful monitoring of renal parameters should be performed in patients on prolonged therapy with cefepime.

View Article: PubMed Central - PubMed

Affiliation: Department of Renal Medicine, South Western Sydney Local Health District, Liverpool, NSW, 2170, Australia. kmac0605@gmail.com.

ABSTRACT

Background: Nephrotoxicity due to drugs especially beta lactams and cephalosporins has been well recognised. Cefepime is a fourth-generation cephalosporin that is widely prescribed with few severe adverse reactions reported. Although cefepime induced neurotoxicity has frequently been reported, there is yet no reported case of acute interstitial nephritis caused by this drug. We report a biopsy proven case of acute kidney injury due to acute interstitial nephritis associated with use of cefepime for treatment of mastoiditis and temporal bone osteomyelitis.

Case presentation: A 62-year-old Caucasian female presented with symptoms of right sided mastoiditis. A brain Magnetic Resonance Imaging scan revealed presence of right sided mastoiditis with concurrent temporal bone osteomyelitis. Microbiological specimen isolated an Escherichia coli. Therapy was commenced with intravenous cefepime. After 4 weeks of therapy with intravenous cefepime she developed acute kidney injury. No other medications were taken by the patient. Urine analysis revealed non-nephrotic range proteinuria. There was no red cell casts or white cell casts. Renal biopsy confirmed acute interstitial nephritis as cause of acute kidney injury. Cefepime therapy was ceased and treatment with ciprofloxacin was given to complete the treatment course. Renal function improved only partially with conservative management without any corticosteroid use. To our knowledge this is the first report of cefepime induced interstitial nephritis.

Conclusions: Although cefepime has been considered to be a safe antibiotic from nephrotoxicity point, like other cephalosporins this adverse effect can occur rarely. Physicians need to be mindful of nephrotoxicity associated with its use and careful monitoring of renal parameters should be performed in patients on prolonged therapy with cefepime.

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Related in: MedlinePlus

Renal biopsy showed interstitial fibrosis with patchy areas of inflammatory cells infiltration. Haematoxylin & Eosin stain x2.5, x40 hpf (red arrow-showing lymphocyte infiltration and interstitial fibrosis, yellow arrow-lymphocytes clusters).
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Fig3: Renal biopsy showed interstitial fibrosis with patchy areas of inflammatory cells infiltration. Haematoxylin & Eosin stain x2.5, x40 hpf (red arrow-showing lymphocyte infiltration and interstitial fibrosis, yellow arrow-lymphocytes clusters).

Mentions: During her inpatient stay all medications except metoprolol were ceased. Though she was clinically euvolaemic and suffered from non-oliguric renal failure, 36 hours trial of intravenous hydration with normal saline (0.9% w/v) at 80 ml/hour was administered with minimal effect on serum creatinine, blood urea and serum electrolytes. Marginal increase of urine output was noted which was commensurate with the intravenous fluid administered. Laboratory investigations of aetiology of AKI were negative or not detected. This included: Double stranded DNAs, ANCA, extractable nuclear antigens, rheumatoid factor, serum and urine protein electrophoresis, complement levels, immunoglobulin subclasses, streptococcal serology and hepatitis B and C serology. An ANA titre of 1:1280 (homogenous pattern) was noted and was thought to be related as a reaction due to cefepime therapy. Renal ultrasound revealed normal renal size, parenchyma and no obstructive uropathy. A renal biopsy showed moderate tubular atrophy with many intra-tubular casts in the medullary area. A few tubules were distended with cellular debris and acute inflammatory exudate (acute tubulitis). Moderate interstitial fibrosis was present with patchy areas of inflammatory infiltrates comprising predominantly lymphocytes, plasma cells and neutrophils. Eosinophils were not detected in the renal biopsy. Periodic acid Schiff stain and Gomori -silver stain were negative on the biopsy. Immunofluorescence staining was negative for IgA, IgG, IgM, kappa and lambda light chains, C1q, C3, amyloid and fibrinogen. Electron microscopy did not reveal any glomerular abnormality. (Figure 3)Figure 3


Cefepime induced acute interstitial nephritis--a case report.

Mac K, Chavada R, Paull S, Howlin K, Wong J - BMC Nephrol (2015)

Renal biopsy showed interstitial fibrosis with patchy areas of inflammatory cells infiltration. Haematoxylin & Eosin stain x2.5, x40 hpf (red arrow-showing lymphocyte infiltration and interstitial fibrosis, yellow arrow-lymphocytes clusters).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4359532&req=5

Fig3: Renal biopsy showed interstitial fibrosis with patchy areas of inflammatory cells infiltration. Haematoxylin & Eosin stain x2.5, x40 hpf (red arrow-showing lymphocyte infiltration and interstitial fibrosis, yellow arrow-lymphocytes clusters).
Mentions: During her inpatient stay all medications except metoprolol were ceased. Though she was clinically euvolaemic and suffered from non-oliguric renal failure, 36 hours trial of intravenous hydration with normal saline (0.9% w/v) at 80 ml/hour was administered with minimal effect on serum creatinine, blood urea and serum electrolytes. Marginal increase of urine output was noted which was commensurate with the intravenous fluid administered. Laboratory investigations of aetiology of AKI were negative or not detected. This included: Double stranded DNAs, ANCA, extractable nuclear antigens, rheumatoid factor, serum and urine protein electrophoresis, complement levels, immunoglobulin subclasses, streptococcal serology and hepatitis B and C serology. An ANA titre of 1:1280 (homogenous pattern) was noted and was thought to be related as a reaction due to cefepime therapy. Renal ultrasound revealed normal renal size, parenchyma and no obstructive uropathy. A renal biopsy showed moderate tubular atrophy with many intra-tubular casts in the medullary area. A few tubules were distended with cellular debris and acute inflammatory exudate (acute tubulitis). Moderate interstitial fibrosis was present with patchy areas of inflammatory infiltrates comprising predominantly lymphocytes, plasma cells and neutrophils. Eosinophils were not detected in the renal biopsy. Periodic acid Schiff stain and Gomori -silver stain were negative on the biopsy. Immunofluorescence staining was negative for IgA, IgG, IgM, kappa and lambda light chains, C1q, C3, amyloid and fibrinogen. Electron microscopy did not reveal any glomerular abnormality. (Figure 3)Figure 3

Bottom Line: Renal function improved only partially with conservative management without any corticosteroid use.Although cefepime has been considered to be a safe antibiotic from nephrotoxicity point, like other cephalosporins this adverse effect can occur rarely.Physicians need to be mindful of nephrotoxicity associated with its use and careful monitoring of renal parameters should be performed in patients on prolonged therapy with cefepime.

View Article: PubMed Central - PubMed

Affiliation: Department of Renal Medicine, South Western Sydney Local Health District, Liverpool, NSW, 2170, Australia. kmac0605@gmail.com.

ABSTRACT

Background: Nephrotoxicity due to drugs especially beta lactams and cephalosporins has been well recognised. Cefepime is a fourth-generation cephalosporin that is widely prescribed with few severe adverse reactions reported. Although cefepime induced neurotoxicity has frequently been reported, there is yet no reported case of acute interstitial nephritis caused by this drug. We report a biopsy proven case of acute kidney injury due to acute interstitial nephritis associated with use of cefepime for treatment of mastoiditis and temporal bone osteomyelitis.

Case presentation: A 62-year-old Caucasian female presented with symptoms of right sided mastoiditis. A brain Magnetic Resonance Imaging scan revealed presence of right sided mastoiditis with concurrent temporal bone osteomyelitis. Microbiological specimen isolated an Escherichia coli. Therapy was commenced with intravenous cefepime. After 4 weeks of therapy with intravenous cefepime she developed acute kidney injury. No other medications were taken by the patient. Urine analysis revealed non-nephrotic range proteinuria. There was no red cell casts or white cell casts. Renal biopsy confirmed acute interstitial nephritis as cause of acute kidney injury. Cefepime therapy was ceased and treatment with ciprofloxacin was given to complete the treatment course. Renal function improved only partially with conservative management without any corticosteroid use. To our knowledge this is the first report of cefepime induced interstitial nephritis.

Conclusions: Although cefepime has been considered to be a safe antibiotic from nephrotoxicity point, like other cephalosporins this adverse effect can occur rarely. Physicians need to be mindful of nephrotoxicity associated with its use and careful monitoring of renal parameters should be performed in patients on prolonged therapy with cefepime.

Show MeSH
Related in: MedlinePlus