Rhabdomyolysis-associated acute kidney injury: Answers

Diarrhea followed by the onset of oliguria and renal failure together with thrombocytopenia brings to mind hemolytic uremic syndrome, which was disregarded as a diagnosis in our patient because of the absence of anemia, normal levels of reticulocyte, lactate dehydrogenase and haptoglobulin and no evidence of hemolysis in the blood smear. Elevated creatine kinase and myoglobin levels are suggestive of rhabdomyolysis and may lead to kidney failure. The causes of rhabdomyolysis are trauma, intense exercise, ischemia, drugs, infectious causes or metabolic diseases [1]. The presence of leukocytosis, elevated C-reactive protein and procalcitonin levels bring infectious causes into the forefront as differential diagnoses. Leptospira is an infectious agent that can start with diarrhea and result in icterus and hepatomegaly [2].

Leptospira are Gram-negative bacteria that do not stain well with Gram stain [3]. Dark field microscopy can reveal the presence of a mobile bacillus [4]. Culturing is a method with a very low chance of success, but it is a definite diagnostic method. Two types of serological examination methods can be used. The first one is the macroagglutination method, which is more appropriate for the diagnosis of past infections, but its sensitivity for early diagnosis is not sufficient. The second serological method is the microscopic agglutination test [5]; however, standardization of this test is difficult at high specificity. In addition, a specific study can be performed on serovar. Our patient was positive for Leptospira icterohaemorrhagiae at a titer of 1/800 with microscopic agglutination test.

Leptospira reservoirs are rodents, dogs and pigs. There is chronic renal involvement in animals, and bacteria are continuously excreted into the urine. Infection with bacteria occurs by contact with contaminated water or soil [6]. Bacteria enter the body through damaged skin or intact mucous tissue. When the patient, who has a history of swimming in the river, was re-questioned, he reported that he had a cut in his left ankle at that time.

In rhabdomyolysis, the basis of treatment consists of fluid replacement and urine alkalinization. Parenteral penicillin therapy for leptospira treatment is recommended in severe cases, while oral doxycycline/tetracycline or ampicillin can be used in patients with a mild course [7]. On admission, our patient was started empirically on ceftriaxone treatment, and doxycycline was added to the treatment during follow-up. Two sessions of renal replacement therapy were performed during follow-up. Serum creatinine level and platelet count returned to normal on the sixth day of antibiotic therapy, and myoglobin and creatine kinase levels returned to normal on the seventh day, whereas normalization of bilirubin levels took up to 7 weeks.