Abstract
Substance abusers are at increased risk of acute kidney injury (AKI) compared to the general population due to nontraumatic rhabdomyolysis. The primary target of these nephrotoxic agents is the tubulointerstitial compartment and the most frequent findings on biopsy are consistent with acute tubular necrosis (ATN) and acute interstitial nephritis. We present a rare case of an intravenous cocaine and heroin abuser who presented with recent onset oliguria, hematuria, and reduced peroral intake. The urine dipstick testing showed guaiac positivity but no red blood cells on microscopy. The blood workup showed elevated serum creatinine and urea levels but normal creatinine kinase (CK) level. Renal biopsy showed tubular epithelial cell necrosis and positive immunoperoxidase staining for myoglobin pigment casts in renal tubules. The diagnosis of rhabdomyolysis-associated ATN secondary to substance abuse was suggested. However, normal serum CK levels as well as urine drug panel supported the delayed presentation of rhabdomyolysis complicated with ATN. The patient returned to normal health with no residual kidney dysfunction after undergoing temporary hemofiltration.
Highlights
Heme pigment (HP)-containing protein molecules such as myoglobin and hemoglobin are essential for the normal functioning of myocytes and red blood cells (RBC), respectively
RM-associated acute tubular necrosis (ATN) following substance abuse presents with many fold rise in plasma creatinine kinase (CK) levels and myoglobinuria [3], but we are reporting a unique presentation of RM-associated ATN with normal serum CK levels and positive immunoperoxidase staining for myoglobin tubular casts on renal biopsy
The higher creatinine levels upon presentation with normal serum CK titers and positive myoglobin staining renal tubular casts suggested the delayed presentation of substance-related RM complicated with ATN until the normalization of serum CK levels
Summary
Heme pigment (HP)-containing protein molecules such as myoglobin and hemoglobin are essential for the normal functioning of myocytes and red blood cells (RBC), respectively. RM-associated ATN following substance abuse presents with many fold rise in plasma CK levels and myoglobinuria [3], but we are reporting a unique presentation of RM-associated ATN with normal serum CK levels and positive immunoperoxidase staining for myoglobin tubular casts on renal biopsy. The purpose of this case is to make the physician aware of an unusual presentation of muscle injury following intravenous drug abuse (heroin and cocaine) and highlight the need for an alternative non-invasive diagnostic tool for the diagnosis of RM-associated ATN with normal. His liver enzymes had returned to normal values at the one-month follow-up visit
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