CASE REPORT: SULPHAMETHOXAZOLE INDUCED CRYSTALLURIA AS A COMPLICATION OF TREATMENT OF PNEUMOCYSTIS JIROVECI PNEUMONIA FOLLOWING STEROID TREATMENT FOR ACUTE INTERSTITIAL NEPHRITIS

A MAHER1, V HERON1, S GOVINDARAJULU1
1Renal Service, Darling Downs Hospital and Health Service, South Toowoomba, Australia

Background: The use of corticosteroids in acute interstitial nephritis is controversial, however may be utilised if patients do not have a significant improvement in creatinine within one week of cessation of the culprit medication.
Case Report: We report a case of a 77 year old male who presented with an acute kidney injury with renal biopsy findings suggestive of acute interstitial nephritis secondary to a course of penicillins for a gluteal abscess. His renal function continued to decline with his creatinine peaking at 218umol/L from a baseline of 77umol/L. He was initiated on 75mg of prednisolone (patient weight 125kg). Three weeks post commencement of prednisolone his creatinine had improved to 113umol/L. However, at this time, his treatment course was complicated by rapidly progressive dyspnoea and hypoxia requiring admission with room air saturations of 73%. A high resolution CT chest demonstrated widespread, non-specific ground glass opacifications in both lungs. A bronchoscopy and subsequent culture confirmed an opportunistic infection with Pneumocystis jiroveci pneumonia (PJP). Sulfamethoxazole Trimethoprim (1600mg/320mg) four times a day was initiated. One week later, he developed a thick, mud-like urinary sediment associated with deterioration in renal function with his creatinine incrementing from 125umol/L to 260umol/L. Urine microscopy with infrared spectroscopy demonstrated needle-shaped crystals, consistent with sulfonamide usage. The offending agent was ceased and his PJP was managed with clindamycin and primaquine with a subsequent improvement in both pulmonary and renal function. At time of discharge his creatinine was 93umol/L.
Conclusions: This case demonstrates the importance of the use of PJP prophylaxis whilst on high dose steroids and the awareness of the potential renal complications of sulphomethaxole induced crystalluria.


Biography:
Vanessa Heron is an advanced trainee in nephrology working in the renal department at Toowoomba Hospital.

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