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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 5  |  Page : 981-983
Ergotamine-induced acute tubulo-interstitial nephritis


1 Department of Internal Medicine, Namazi Hospital, Shiraz University of Medical Sciences; Shiraz NephroUrology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
2 Department of Internal Medicine, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
3 Shiraz NephroUrology Research Center, Shiraz University of Medical Sciences; Pathology Ward, Shiraz University of Medical Sciences, Shiraz, Iran
4 Shiraz NephroUrology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

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Date of Web Publication12-Sep-2013
 

   Abstract 

Ergotamine has been used for the treatment of migraine for many years, and its use in adults is considered to be safe and effective. In this report, we present a 22-year-old female patient, a known case of migraine, who was on ergotamine tartrate and presented with hypertension and renal failure. Renal biopsy indicated features of acute tubulo-interstitital nephritis.

How to cite this article:
Pakfetrat M, Rasekhi A, Eftekhari F, Hashemi N, Roozbeh J, Torabineghad S, Malekmakan L. Ergotamine-induced acute tubulo-interstitial nephritis . Saudi J Kidney Dis Transpl 2013;24:981-3

How to cite this URL:
Pakfetrat M, Rasekhi A, Eftekhari F, Hashemi N, Roozbeh J, Torabineghad S, Malekmakan L. Ergotamine-induced acute tubulo-interstitial nephritis . Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Jul 21];24:981-3. Available from: http://www.sjkdt.org/text.asp?2013/24/5/981/118100

   Introduction Top


Ergotamine intoxication can cause vasoconstriction, which may result in ischemia in many organs such as heart, splanchnic organs and the kidneys. In this report, we present a case of chronic ergotamine intoxication in a patient who presented with hypertension and acute renal failure due to ergotamine-induced acute tubulo-interstitial nephritis.


   Case Report Top


The patient is a 22-year-old girl, a case of chronic intermittent headache that was diagnosed as migraine, and was on treatment with ergotamine tartrate 2-4 mg (variable doses) daily for 4 years. She was admitted to the hospital for complaints of severe headache, nausea and vomiting. Medical history was unremarkable except for rupture of the ovarian cyst a few years earlier. Her grandmother and uncle had hypertension. Physical examination revealed a febrile girl; blood pressure was 240/140 mmHg in both arms with regular pulses. There was no evidence of thyromegaly or lymphadenopathy. Heart and lung auscultation was unremarkable. Abdomen was soft with no organomegaly. There was no edema in the extremities and all pulses were present bilaterally and were symmetrical. Neurological examination was normal. Laboratory data at admission revealed: Serum createnine of 3.8 mg/dL (0.8 mg/dL 2 months earlier), blood urea nitrogen of 32 mg/dL, leukocyte count of 17,300/mm 3 , hemoglobin of 10.8 mg/ dL and erythrocyte sedimentation rate of 40 mm/h. Urinalysis showed 15 leukocytes/mm 3 and four red blood cells/mm 3 ; there was no proteinuria. Liver and thyroid function tests were normal and immunologic and viral markers were unremarkable. The serum aldosterone, aldosterone/renine ratio, serum metanephrin and normetanephrin levels were normal. Abdominal sonography revealed bilateral, normal-sized kidneys and no other abnormalities. Computerized tomography (CT) angiography of the abdominal arteries indicated no evidence of renal artery stenosis. Echocardiography showed early stages of hypertensive heart. A renal biopsy showed acute tubulointerstitial nephritis, glomerular ischemic changes and vascular changes suggestive of benign nephrosclerosis [Figure 1] and [Figure 2]. The patient's blood pressure was controlled with losartan 25 mg orally thrice daily and amlodipine 5 mg orally twice daily. The headache improved when the blood pressure was brought under control. Prednisolone, in a dose of 60 mg/day, was started for the patient. The serum creatinine decreased to 2.2 mg/dL after 6 weeks. The anti-hypertensive medications had to be continued for control of blood pressure and renal function became stable, with serum creatinine reaching 1.6 mg/dL after 6 months.
Figure 1. Light microscopic picture of the renal interstitium showing significant inflammation

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Figure 2. Light microcopy showing a single normal glomerulus and interstitial inflammation

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   Discussion Top


Ergotamine is one of the about 80 known, naturally occurring ergot alkaloids that are produced by the phyto-pathogenic fungus, Claviceps purpurea, as well as by other toxigenic filamentous fungi and higher plants. [1]

Ergotamine is structurally similar to endogenous catecholamines and exhibits affinity for serotonergic, dopaminergic and α-adrenergic receptors. [2] Ergotism-related severe/sustained vasoconstriction may involve many vascular beds (e.g., carotid, coronary, retinal, mesenteric, renal and uterine), causing different symptoms. [3],[4],[5],[6],[7]

Fievez et al reported a 29-year-old hypertensive woman with typical features of fibro muscular dysplasia caused by chronic intoxication with ergotamine tartrate. [8] Aabech et al described 14 patients with peripheral vascular complications with acute ergotism, [9] while Fedotin et al described a patient with ergotamine poisoning who had renal arterial spasm. [10]

In 1977, Pursey et al reported a 42-year-old housewife who presented with a 2-week history of headache, vomiting, debility, confusion and cold painful hands. She was a known case of migraine and had taken ten 1 mg dihydroergotamine tablets daily for 2 weeks and 20 tablets the day before admission. She presented with acute renal failure and recovery of renal function was noted 3 weeks after the drug was ziscontinued. [11]

More recently, Janssen van Doorn et al described a 48-year-old female treated with ergotamine tartrate suppositories for 10 years who presented with acute tubulo-interstitial nephritis and renal infarction. Renal functions recovered after 6 weeks of treatment with corticosteroids. [12]

The case we have described received ergotamine as the sole medication for the treatment of chronic headache and presented with hypertension and renal failure. Renal biopsy showed features typical of acute tubulo-interstitital nephritis. The patient had partial recovery of serum creatinine at 2.2 mg/dL after 6 weeks of corticosteroid therapy. The mechanism of development of tubulo-interstitial nephritis, especially in this case, is not completely understood. Renal arterial diseases including benign arterioand/or arteriolo-sclerotic and malignant nephrosclerosis, renal infarction and renal cortical necrosis may all induce tubulo-interstitial lesions. In these conditions, the renal glomeruli as well as the tubules are always involved with consequent loss of nephrons or renal parenchyma resulting in interstitial fibrotic changes. [13]

Additionally, the ergot alkaloids inhibit sodium-potassium ATPase and, to a lesser degree, magnesium ATPase in the kidney, which, besides causing benign nephrosclerosis, may be one of the explanations for tubular damage in this case. [14]


   Acknowledgments Top


This study was funded by the Shiraz Nephro-Urology Research Center of the Shiraz University of Medical Sciences.

Conflict of Interest: The authors declare no conflict of interest.

 
   References Top

1.Schiff PL. Ergot and its alkaloids. Am J Pharm Educ 2006;70:98.  Back to cited text no. 1
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2.Tfelt-Hansen P, Saxena PR, Dahlöf C, et al. Ergotamine in the acute treatment of migraine: A review and European consensus. Brain 2000;123:9-18.  Back to cited text no. 2
    
3.Akova-Oztürk E, Husstedt IW, Ringelstein EB, Evers S. Carotid artery dissection in ergotamine abuse. Headache 2004;44:930-2.  Back to cited text no. 3
    
4.Rostoff P, Gajos G, Latacz P, Wozniczko M, Matysek J, Piwowarska W. Ergotamine-induced cardiovascular toxicity: Mechanisms and clinical significance. Int J Cardiol 2010;141:111-4.  Back to cited text no. 4
[PUBMED]    
5.Wollensak J, Grajewski O. Bilateral vascular papillitis following ergotamin medication. Klin Monatsbl Augenheilkd 1978;173:731-7.  Back to cited text no. 5
[PUBMED]    
6.Rutgeerts L, Ghillebert G, Drognee W, Tanghe W, Vuylsteke P, Decoster M. Ischemic colitis in a patient with Crohn's disease taking an oral contraceptive and an ergotamine alkaloid. Acta Clin Belg 1993;48:48-51.  Back to cited text no. 6
[PUBMED]    
7.Smets K, Zecic A, Willems J. Ergotamine as a possible cause of Möbius sequence: Additional clinical observation. J Child Neurol 2004;19: 398.  Back to cited text no. 7
[PUBMED]    
8.Fievez M, Koerperich G, Dulieu J. Arterial fibromuscular dysplasia and ergotism. Ann Anat Pathol 1975;20:357-66.  Back to cited text no. 8
    
9.Aabech J, Jensen FB, Engell HC. Ergotism in migraine. Peripheral vascular complications in 14 patients with migraine. Ugeskr Laeger 1989; 151:2067-70.  Back to cited text no. 9
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10.Fedotin MS, Hartman C. Ergotamine poisoning producing renal arterial spasm. N Engl J Med 1970;283:518-20.  Back to cited text no. 10
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11.Pusey CD, Rainford DJ. St Anthony's fire and pseudochronic renal failure. Br Med J 1977;2: 935.  Back to cited text no. 11
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12.Janssen van Doorn K, Van der Niepen P, van Tussenbroeck F, Verbeelen D. Acute tubulointerstitial nephritis and renal infarction secondary to ergotamine therapy. Nephrol Dial Transplant 2000;15:1877-9.  Back to cited text no. 12
[PUBMED]    
13.Kida H, Yoshimura M. Renal arterial disease-induced tubulo-interstitial lesions. Nippon Rinsho 1995;53:2034-9.  Back to cited text no. 13
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14.Moubarak AS, Johnson ZB, Rosenkrans CF. Antagonistic effects of simultaneous exposure of ergot alkaloids on kidney adenosine triphosphatase system. In Vitro Cell Dev Biol Anim 2003;39:395-8.  Back to cited text no. 14
[PUBMED]    

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Correspondence Address:
Leila Malekmakan
Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, P. O. Box 71348-14336, Shiraz
Iran
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DOI: 10.4103/1319-2442.118100

PMID: 24029265

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    Abstract
   Introduction
   Case Report
   Discussion
   Acknowledgments
    References
    Article Figures
 

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