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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 28  |  Issue : 1  |  Page : 178-180
Typhoid-associated acute kidney injury masquerading as a relapse of Takayasu arteritis


Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

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Date of Web Publication12-Jan-2017
 

   Abstract 

Renal dysfunction is common in Takayasu arteritis. Uncommonly, renal failure in a case of Takayasu arteritis can be due to an unrelated disease, and if the disease is a rare complication, it is even more difficult to diagnose. We report a 21-year-old male with type IV Takayasu arteritis presenting with fever and renal failure, who was diagnosed to have enteric fever- related glomerulonephritis which was successfully treated.

How to cite this article:
Manjunath R, Kaul A, Sharma RK, Bhadauria DS, Prasad N, Gupta A. Typhoid-associated acute kidney injury masquerading as a relapse of Takayasu arteritis. Saudi J Kidney Dis Transpl 2017;28:178-80

How to cite this URL:
Manjunath R, Kaul A, Sharma RK, Bhadauria DS, Prasad N, Gupta A. Typhoid-associated acute kidney injury masquerading as a relapse of Takayasu arteritis. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2017 Mar 27];28:178-80. Available from: http://www.sjkdt.org/text.asp?2017/28/1/178/198270

   Introduction Top


Takayasu arteritis is one of the common varieties of vasculitis seen in South Asian population. It is known to have relapsing- remitting course. Kidneys are one of the major organs involved. Renal failure in Takayasu arteritis can be prevented if the systemic disease is appropriately treated. However, the renal dysfunction in a patient with known Takayasu arteritis can be due to various causes, necessitating case-specific evaluation. We report a case of Takayasu arteritis with renal dysfunction.


   Case Report Top


A 22-year-old male presented to our follow-up clinic with history of fever, generalized myalgia, and headache for 10 days, decreased urine output, edema, and smoky urine for three days. His medical history included hypertension since the age of 19 years. He was evaluated for hypertension at our hospital and was diagnosed to be secondary to type IV Takayasu arteritis. He was started on prednisolone 1 mg/kg/day. He was lost to follow-up for two months, only to present later on with accelerated hypertension, right contracted kidney, and renal dysfunction (serum creatinine 281.6 μmol/L). He was managed with antihypertensive medications and prednisolone. Eventually, serum creatinine settled at 96.8 μmol/L. In view of uncontrolled hypertension and solitary functioning kidney, angioplasty of the left renal artery was done without any success. After the control of the disease activity, he underwent renal artery stenting with Formula™ (Cook Medical, Bloomington, IN). Hypertension was controlled on three drugs, with antihypertensive dose decreased by 50%; steroid was gradually tapered and stopped. On his last follow-up visit, three months before this presentation, he was off prednisolone, had well-controlled blood pressure on ramipril and furosemide. His renal function, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal.

Clinical examination showed pedal edema, heart rate of 68 beats/min, and temperature of 103°F. Blood pressure was 170/90 mm Hg. The rest of the clinical examination was unremarkable. Relevant investigations were sent. He was started on ceftriaxone 2 g/day and symptomatic medications. Investigations revealed total leukocyte count of 3.8 × 10[9]/L, renal dysfunction (serum creatinine 369.6 μmol/L), high serum C3 (1.56 g/L), and C4 (0.49 g/L). He had a CRP of 5.6 mg/L and ESR of 51 mm/h. Urine analysis showed microscopic hematuria (35-40 red blood cells/high-power field and proteinuria (2+). Spot urine analysis showed a protein creatinine ratio of 1.87. On day 6, his leukopenia recovered, s. creatinine decreased to 167.2

μmol/L. His blood culture grew Salmonella typhi, sensitive to ceftriaxone, and ciprofloxacin. The ongoing treatment with ceftriaxone was continued. After eight days of antibiotics, he became afebrile. He was discharged on day 16 with stable renal function (serum creatinine 114.4 μmol/L), microscopic hematuria, and proteinuria.

On follow-up, it was noted that his antihypertensive dose was decreased, hematuria recovered by 5th month, proteinuria recovered by 7th month. At his last follow-up, he had a wellcontrolled blood pressure on ramipril and furosemide, with serum creatinine 96.8 μmol/L, the baseline value for this patient and an unremarkable urine analysis.


   Discussion Top


Takayasu arteritis commonly involves kidneys. It has a relapsing-remitting course. However, relapse may be misdiagnosed if not carefully interpreted. In our case, presentation with fever, hypertension, renal dysfunction, and raised ESR could have misled to a diagnosis of a relapse. The presence of microscopic hematuria and proteinuria, which is unusual for a case of Takayasu arteritis relapse,[1] alerted us for an alternative diagnosis. Hence, steroids were withheld. In view of hypertension associated with high-grade fever, smoky urine, microscopic hematuria, and proteinuria, infectionrelated glomerulonephritis was considered. The blood culture taken at presentation was later reported to have grown S. typhi. Isolation of S. typhi from blood, bone marrow, is required for the definitive diagnosis of enteric fever. Blood culture has a sensitivity of 40-80%; bone marrow culture is 55-90% sensitive, and not affected by prior antibiotic therapy up to five days.

In our case, kidney biopsy was not done in view of the solitary functioning kidney. However, the presentation, laboratory evaluation, and the response to therapy with recovery of renal function, all support our diagnosis of infection-related glomerulonephritis or acute interstitial nephritis.

The diagnosis of enteric fever in endemic areas is easier when it presents with classical features. However, when it is an unusual presentation with a rare complication, it carries a risk of delaying the diagnosis and mistreating. Glomerulonephritis, acute interstitial nephritis,[1] ,[2] pyelonephritis, and cystitis are rarely reported urinary complications of enteric fever.[1] Other renal pathology reported with enteric fever is acute tubular necrosis, IgA Nephropathy, hemolytic-uremic syndrome, Henoch-Schφnlein purpura.[3] ,[4] ,[5] ,[6] The incidence of these complications has decreased in view of prompt antibiotic treatment. Literature review reveals typhoid fever to be occasionally reported to cause glomerulonephritis, varying from asymptomatic urinary abnormality to acute renal failure.[7] Overt glomerulonephritis is noted in about 2% of cases of acute enteric fever. However as many as 25% of these patients can have micros copic hematuria and proteinuria.[8] Most of these reports are from developing countries, decades ago. With globalization and re-worsening of sanitary conditions, epidemic episodes of enteric fever are still reported.[9]

Enteric fever-related GN and acute interstitial nephritis may be underdiagnosed (misinterpretation of reports/empirical treatment concealing the disease) or underreported.[2] ,[10] ,[11]

Conflict of interest: None declared.

 
   References Top

1.
Appel GB, Radhakrishnan J, D'Agati VD. Secondary glomerular diseases. In: Taal MW, Chertow GM, Marsden PA, Skorecki K, Yu AS, Brenner BM, eds. Brenner & Rector's the Kidney. 9th ed. 2015 Elsevier Saunders; Philadelphia p. 1220-1.  Back to cited text no. 1
    
2.
Dhooria GS, Bains HS, Bhat D. Proliferative glomerulonephritis causing acute renal failure in a child with Salmonella septicemia. Indian J Nephrol 2013;23:240-1.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Dutta TK, Beeresha, Ghotekar LH. A typical manifestations of typhoid fever. J Postgrad Med 2001;47:248-51.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Youmbissi TJ, Malik TQ, Ajit Kumar S, Rafi A, Al Khursanny AI, Karkar A. Henoch-Schönlein nephritis and Salmonella typhi septicaemia. Nephrol Dial Transplant 2001;16:1081-2.  Back to cited text no. 4
    
5.
Albaqali A, Ghuloom A, Al Arrayed A, et al. Hemolytic uremic syndrome in association with typhoid fever. Am J Kidney Dis 2003;41:709-13.  Back to cited text no. 5
    
6.
Indraprasit S, Boonpucknavig V, Boonpucknavig S. IgA nephropathy associated with enteric fever. Nephron 1985;40:219-22.  Back to cited text no. 6
    
7.
Buka I, Coovadia HM. Typhoid glomerulonephritis. Arch Dis Child 1980;55:305-7.  Back to cited text no. 7
    
8.
Chugh KS, Sakhuja V. Glomerular diseases in the tropics. Am J Nephrol 1990;10:437-50.  Back to cited text no. 8
    
9.
Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bull World Health Organ 2004;82:346-53.  Back to cited text no. 9
    
10.
Bhatt GC, Nandan D. Salmonella typhi presenting as acute glomerulonephritis in twin siblings. Trop Doct 2012;42:235-6.  Back to cited text no. 10
    
11.
Caers J, Peeters P, Vanden Houte K, Sennesael J, Van der Niepen P, Verbeelen D. Acute interstitial nephritis associated with salmonellosis. Eur J Intern Med 2006;17:217-9.  Back to cited text no. 11
    

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Correspondence Address:
Revanasiddappa Manjunath
Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
India
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DOI: 10.4103/1319-2442.198270

PMID: 28098123

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    Abstract
   Introduction
   Discussion
   Case Report
    References
 

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