chiaroscuro27 Posted March 29, 2011 Share Posted March 29, 2011 I'd like to get an echo to see the extent of the mitral regurg. Perhaps this is the source of her prerenal kidney failure. I'll be back to add more. Link to comment Share on other sites More sharing options...
deborah212 Posted March 29, 2011 Author Share Posted March 29, 2011 The question now is... what caused the AKI?Excellent! She has acute renal failure that is now the likely culprit of her delirium (waxing/waning mental status). Urine Na 59 Urine Cr 63.8 I typically send a FeBUN when the patient is on diuretic therapy. but the ratio would favor infrarenal causeSo what does the FENa suggest? How can we work this up further? I'd like to get an echo to see the extent of the mitral regurg. Perhaps this is the source of her prerenal kidney failure. I would hold off going down this route. By exam, the patient does not have evidence of heart failure. This murmur (you are correct in that this is likely MR) is probably old and a function of her HTN and age. Still good to think broadly... I once admitted a patient with fever, a new holosystolic murmur, and ARF. He had embolized both his spleen and kidneys from endocarditis and ended up requiring an intra-aortic balloon pump to maintain hemodynamic stability until the valve could be replaced. I can tell you that our patient has another reason for ARF. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 29, 2011 Administrator Share Posted March 29, 2011 So, running all those numbers, FeNA = 1.8%, again pointing to intrarenal. ATN seems most congruent with findings to date. More investigations: * Did we check the urine for cells and/or casts? * Review Hx for any recent contrast agents (longshot...) Ideas: * Possible side effect of the ACEI? Stop it and see. * Allergic reaction to the cipro (again, longshot...) * Fluid challenge with NS? Link to comment Share on other sites More sharing options...
deborah212 Posted March 29, 2011 Author Share Posted March 29, 2011 * Did we check the urine for cells and/or casts? * Allergic reaction to the cipro (again, longshot...)Microscopic analysis of urine reveals a very active urine sediment with many WBCs and WBCs casts (as suggested by the 3+ LE on the initial UA). Few RBCs. Chiaroscuro27 found something when we ordered labs that tipped me off to the diagnosis before getting the results of the sediment. What did we miss? What else should we ask the lab to add on to the sediment (not performed routinely at least at my hospital)? * Review Hx for any recent contrast agents (longshot...)[./QUOTE]No but we are missing something in the history that supports the diagnosis though can be made without knowing. * Fluid challenge with NS? Let's wait to discuss treatment until we come to a consensus on the diagnosis. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted March 29, 2011 Share Posted March 29, 2011 Another question: any crystals seen on UA? Perhaps there is a intrarenal obstruction. Link to comment Share on other sites More sharing options...
marilynpac Posted March 29, 2011 Share Posted March 29, 2011 deborah 212, thank you for this thread, it makes us do our exercise in mental gymnastics.... Link to comment Share on other sites More sharing options...
deborah212 Posted March 30, 2011 Author Share Posted March 30, 2011 Another question: any crystals seen on UA? Perhaps there is a intrarenal obstruction. No crystals but it is indeed an intrarenal process. Think back to your nephrology lectures... Glomerulonephritis causes RBC casts whereas _______ causes WBC casts. Rev Ronin has already correctly identified one of the causes in this scenario. Hint: What's abnormal about the differential on our CBC? This should also be tested on the urine. Renal ultrasound was performed and demonstrated no hydronephrosis, cysts, or inflammatory changes indicative of pyelonephritis. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted March 30, 2011 Share Posted March 30, 2011 Without looking at my notes I believe it's Acute interstitial nephritis where you see WBC casts. Darn it...I think I get it now! The eosinophil count was a bit high...5% right! That's what we should have tested in the urine. Link to comment Share on other sites More sharing options...
rcdavis Posted March 30, 2011 Share Posted March 30, 2011 Brad, are you referring to hydrocephalus? I would quickly comment as an aside that what he is describing is the triad of gait apraxia ( wide based, slow, shuffling), urinary incontinence and /or frequency, plus an altered mental status seen in NPH Normal Pressure Hydrocephalus... In this case virtually r /d out with normal ventricles on the CT. Once you studs and studettes figure out what Deborah is showing you, the very next question should be: why? And I'll return you to the professor Link to comment Share on other sites More sharing options...
deborah212 Posted March 30, 2011 Author Share Posted March 30, 2011 Without looking at my notes I believe it's Acute interstitial nephritis where you see WBC casts. Darn it...I think I get it now! The eosinophil count was a bit high...5% right! That's what we should have tested in the urine. You got it! ++urine eosinophils. This patient had ARF due to acute interstitial nephritis (AIN). The nidus was ciprofloxacin +/- omeprazole which had been started several weeks prior for GERD symptoms (new medication!). Her ACEI, cipro, and PPI were held on admission and Cr began downtrending. Sometimes, patients require a steroid taper in addition to holding the offending agents. What I thought was interesting in this case what that she actually had a peripheral eosinphilia which is classic but rare. Urine culture that was repeated in house was no growth. Hope you enjoyed. Link to comment Share on other sites More sharing options...
rcdavis Posted March 30, 2011 Share Posted March 30, 2011 Deborah, did you entertain doing a focal renal biopsy? Or did the resolution of the arf by stopping the ppi and cipro preclude the risks. Man o man, dispute years of use, PPIs are beginning to be recognized in many drug-drug interactions not previously envisioned. And the fluorquinolones in the elderly really cause a plethora of confusional/ dementia side effects. Davis Link to comment Share on other sites More sharing options...
deborah212 Posted March 30, 2011 Author Share Posted March 30, 2011 Deborah, did you entertain doing a focal renal biopsy? Or did the resolution of the arf by stopping the ppi and cipro preclude the risks. We deferred renal biopsy as her renal failure resolved sans cipro/PPI. What amazed me was this was my second case of cipro/ppi induced AIN within 2 weeks- though the one I presented here was much more classic. And the fluorquinolones in the elderly really cause a plethora of confusional/ dementia side effects. This!! Yes! Before I had her labs, one of the things I was throwing around was cipro-induced delirium. I didn't "believe" it until last year when I was treating an elderly patient with E. coli pyelo, and she started having both visual and auditory hallucinations that resolved with change to a cephalosporin. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted March 30, 2011 Share Posted March 30, 2011 Awesome case, deborah! What a mental workout this has been. I've been on this case all day! Keep 'em coming, and thanks so much for sharing! Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 30, 2011 Administrator Share Posted March 30, 2011 Indeed, sorry I was offline for the conclusion. So I'm looking at Sanford, and for acute, uncomplicated Fem. UTI, Cipro and the other FQs are only indicated as first line when >20% local E. Coli are resistant to TMP-SMX (possible...) or pt. with Sulfa allergy (none known in this case) It just seems like overkill to nuke a UTI with cipro in an elderly patient, but obviously practitioners do it. Why? Is it just a desire to provide fast relief (and not have to see the patient again...) by expecting Cipro to be a fire-and-forget big gun? Link to comment Share on other sites More sharing options...
deborah212 Posted March 30, 2011 Author Share Posted March 30, 2011 Locally, we are seeing resistance to Bactrim which is the likely reason her PCP chose cipro preferentially in an elderly patient whose age predisposes her to a more "complicated" course. As I've said before, what scares me more than MRSA now is the ESBL E. coli and Klebsiella which are frighteningly become more common. As an aside, Bactrim can cause AIN as well. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 30, 2011 Administrator Share Posted March 30, 2011 Fascinating. Thanks for the case! Link to comment Share on other sites More sharing options...
MikeyBoy Posted April 4, 2011 Share Posted April 4, 2011 Just saw this case now- Thanks for sharing Deborah Link to comment Share on other sites More sharing options...
acozadd Posted April 4, 2011 Share Posted April 4, 2011 One of the faculty at my program mentioned that she experienced delerium type symptoms/hallucinations on cipro and I believe she was only in her 30s or 40s at the time when she took it. Probably extremely rare, but it isn't seen only in the elderly. (obviously this case is more involved, but thought I should share.) Link to comment Share on other sites More sharing options...
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