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Abstract
An 18-year-old Ethiopian woman presented with debilitating back pain and high fever. X-ray examinations showed diffuse pulmonary tuberculosis and a psoas abscess. After starting rifampicin, isoniazid, ethambutol and pyrazinamide, acute interstitial nephritis developed that spontaneously recovered. According to Harrison's Online rifampicin should have been causative, but the spontaneous recovery excluded that possibility. The clinical course fit the diagnosis of a paradoxical response, for which recently risk factors have been described. Thus, a paradoxical response should be added to the list of causes of interstitial nephritis in tuberculosis patients and in such cases rifampicin could be continued.
Highlights
Rifampicin, mostly in combination with isoniazid, ethambutol and pyrazinamide, is the first-line therapy for tuberculosis
We present a patient with miliary tuberculosis, who developed interstitial nephritis (IN) during rifampicin, yet spontaneously recovered
Almost all of the patients had rifampicin-dependent antibodies against the I-antigen which is present on erythrocytes and on tubular epithelial cells
Summary
Rifampicin, mostly in combination with isoniazid, ethambutol and pyrazinamide, is the first-line therapy for tuberculosis. Rifampicin’s most feared side effect is hepatotoxicity Nephrotoxicity such as acute tubular necrosis and interstitial nephritis (IN) have been reported. In case of acute tubular necrosis, rifampicin-dependent antibodies have been found, suggesting a causal relationship between rifampicin and renal failure [1]. At the time of renal biopsy serum creatinine was 240 micromol/l and when the result of the biopsy became available it had decreased to 203 micromol/l. Because of this spontaneous recovery, all drugs were continued. Nine months later treatment was stopped and the laboratory data were: Hb 8.0 mmol/l, creatinine 88 micromol/l, serum albumen 39 g/l and protein excretion 0.2 g/day
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