A sixty year old woman, previously healthy, is admitted for acute renal
failure. One week prior to admission she began to feel generally weak with
poor oral intake. There was no diarrhea, abdominal pain, fever, or dysuria.
She did not smoke, drank two gin and tonics daily, and denied any other
drug use. She took no medications. She was seen by a physician two days
prior to admission, was found to have proteinuria and hematuria, and was
placed on amoxicillin for a presumed urinary tract infection. Her labs
subsequently showed a creatinine of 11, platelets of 23, LDH of 4000, and
normal PT and PTT.
The likeliest diagnosis is
1. Acute tubular necrosis related to volume depletion.
2. Thrombotic microangiopathy related to quinine.
3. Interstitial nephritis related to amoxicillin.
4. Hemolytic uremic syndrome related to E. Coli 0157:H7.
5. Thrombotic thrombocytopenic purpura.
6. Renal failure from disseminated intravascular coagulation.
3 comments:
I like the cases (this one and also the previous ones) but where are the answers? Just a suggestion: linking to the answers, possibly with a brief reference to the source, would provide a sense of completion.
My money is on 2.
Answer: 2. Thrombotic microangiopathy related to quinine. Tonic water contains enough quinine to cause hemolytic uremic syndrome in rare cases; the mechanism appears to be related to quinine-dependent anti-platelet antibodies. Clinically, her disease is limited to the kidneys and she has no other manifestions of TTP. (Also, her ADAMTS-13 antibody was negative.)
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